JUDUL
ASUHAN KEPERAWATAN PADA KLIEN DENGAN (..)
Nama :
NIM :
(___________________) (_______________)
UNIVERSITAS BENGKULU
FAKULTAS MATERMATIKA DAN ILMU PENGETAHUAN ALAM
PRODI DIII KEPERAWATAN
TAHUN AKADEMIK 2022/2023
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FORMAT PENGKAJIAN KEPERAWATAN JIWA
( MODEL STRES ADAPTASI STUART, PASARIBU& KELIAT:2016)
I. IDENTITAS KLIEN
Inisial : ……………….. (L/P) Tanggal pengkajian : ………………..
Umur : ……………….. RM No. : ………………..
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2. Pernah mengalami gangguan jiwa sebelumnya:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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4. Riwayat Genetik:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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5. Riwayat Nutrisi:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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6. Riwayat Imunisasi:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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7. Riwayat merokok:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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8. Riwayat alkohol:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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9. Riwayat NAPZA:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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B. PSIKOLOGIS
1. Konsep diri :
a. Gambaran diri : .........................................................................................................................
b. Identitas : .........................................................................................................................
c. Peran : .........................................................................................................................
d. Ideal diri : .........................................................................................................................
e. Harga diri : .........................................................................................................................
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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2. Pola asuh:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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3. Tugas perkembangan:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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4. Intelegensi:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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5. Pertahanan Psikologis:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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6. Pengalaman masa lalu:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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7. Pelaku/ Usia Korban/Usia Saksi/ Usia
a. Aniaya fisik : ……. ……. ……. ……. ……. …….
b. Aniaya seksual : ……. ……. ……. ……. ……. …….
c. Penolakan : ……. ……. ……. ……. ……. …….
d. Kekerasan dalam keluarga : ……. ……. ……. ……. ……. …….
e. Tindakan kriminal : ……. ……. ……. ……. ……. …….
f. Bullying/intimidasi: ……. ……. ……. ……. ……. …….
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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C. SOSIALKULTURAL :
1. Riwayat pendidikan:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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2. Riwayat Pekerjaan/ ekonomi:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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3. Riwayat spiritual/keyakinan/ibadah:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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4. Riwayat budaya:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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5. Riwayat pernikahan/keluarga/tempat tinggal:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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6. Riwayat pergaulan/pertemanan/bermasyarakat:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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7. Riwayat Hospitalisasi/ pelayanan kesehatan:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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8. Riwayat afiliasi politik:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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9. Orang yang berarti: ..................................................................................................................................
10. Genogram :
= Laki-laki
= Perempuan
= Meninggal
= Klien
= Pisah
= Hidup bersama
= Garis keturunan
= Garis perkawinan
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11. Pengambil keputusan dirumah: ................................................................................................................
12. Komunikasi dalam anggota keluarga: ......................................................................................................
13. Di rumah klien dekat dengan: .................................................................................................................
Lainnya:....................................................................................................................................................
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4. Alam perasaan :
Sedih Ketakutan Putus asa Khawatir Gembira berlebihan
Lainnya:....................................................................................................................................................
5. Afek :
Lainnya:....................................................................................................................................................
7. Masalah Persepsi :
Pendengaran Penglihatan Perabaan
Pengecapan Penghidu
Lainnya:....................................................................................................................................................
8. Proses pikir :
Sirkumtansial Tangensial Kehilangan asosiasi
Flight of idea Blocking Pengulangan pembicaraan/perseverasi
Lainnya:....................................................................................................................................................
9. Isi pikir :
Obsesi Fobia Hipokondria
Defersonalisasi ide yang terkait Pikiran magis
Waham
Agama Somatik Kebesaran Curiga
Nihilistic Sisip pikir Siar pikir Kontrol pikir
Lainnya:....................................................................................................................................................
10. Tingkat kesadaran:
Bingung Sedasi Stupor
Disorientasi
Waktu Tempat Orang
Lainnya:....................................................................................................................................................
11. Memori :
Gangguan daya ingat jangka panjang Gangguan daya ingat jk pendek
Gangguan daya ingat saat ini Konfabulasi
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Lainnya:....................................................................................................................................................
Lainnya:....................................................................................................................................................
14. Daya tilik diri :
Mengingkari penyakit yang diderita Menyalahkan hal-hal diluar dirinya
Lainnya:....................................................................................................................................................
2. BAB / BAK
Bantuan minimal Bantuan total
3. Mandi
Bantuan minimal Bantuan total
4. Berpakian / berhias
Bantuan minimal Bantuan total
6. Pengguanaan obat
Bantuan minimal Bantuan total
7. Pemeliharaan kesehatan
Perawatan lanjutan Ya Tidak
Perawatan pendukung Ya Tidak
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9. Kegiatan di luar rumah
Belanja Ya Tidak
Transportasi Ya Tidak
Lain-lain Ya Tidak
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ANALISA DATA
DATA MASALAH
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X. ASPEK MEDIK
Diagnosa Medik : ………………………………………………………….................…………………..
Terapi Medik :
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POHON MASALAH
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DIAGNOSA KEPERAWATAN PERSONAL ABILITY
………………………………..
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INTERVENSI KEPERAWATAN
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IMPLEMENTASI KEPERAWATAN
Nama perawat : Nama Klien : Ruangan :
IMPLEMENTASI TINDAKAN KEPERAWATAN EVALUASI (SOAP)
Tanggal : Jam:
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FORMAT PENILAIAN ASKEP Nama :
NIM:
PKK KEPERAWATAN JIWA Ruangan:
PRODI D III KEPERAWATAN FMIPA UNIB Tanggal/hari:
Pembimbing Lahan:
Pembimbing Pendidikan:
N Persentase NILAI
ASPEK YANG DINILAI
O Nilai (%) 1 2 3 4 5 6 7 8 9 10
Laporan pendahuluan :
- Kelengkapan laporan
1 15
- Kebersihan dan kerapihan
- Ketepatan waktu pengumpulan tugas
Laporan Kasus termasuk SP:
- Kelengkapan laporan
2 25
- Kebersihan dan kerapihan
- Ketepatan waktu pengumpulan tugas
3 Pre dan post Conference 15
4 Ujian Praktek (supervisi) 15
5. Kompetensi 20
Penilaian perilaku: sikap, etika,
4 kedisiplinan, dan kelengkapan atribut 10
seragam
Total
100
Nama mahasiawa : Bengkulu , …………….
1. ………………………… Dosen Pembimbing
2. …………………………
3. …………………………
4. …………………………
5. ……………………….. (…………….…………..)
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