Format Asuhan Keperawatan Jiwa
Format Asuhan Keperawatan Jiwa
PENGKAJIAN
TanggalDirawat:.......................
IDENTITASPASIEN
Nama :.......................................
Umur :.......................................
StatusPerkawinan :.......................................
Agama :.......................................
SukuBangsa :.......................................
Pendidikan :.......................................
Alamat :.......................................
SumberInformasi :.......................................
ALASANMASUK
..........................................................................................................................................
..............................................................................................................................
FAKTORPREDISPOSISI
Pernahmengalamigangguan jiwa dimasalalu?()Ya()Tidak
Pengobatansebelumnya()Berhasil ( )KurangBerhasil ( )
TidakBerhasil
Pelaku/UsiaKorban/UsiaSaksi/Usia
AniayaSeksual ( )()()( )()( )
Penolakan ( )()()( )()( )
KekerasandalamKeluarga ()( )()( )( )()
Jelaskana,b,danc:...............................................................................................
..................................................................................................................................
MasalahKeprawatan: .............................................................................................
P :......................
Ukur:
TB:........................
BB:.....................
Jelaskan:.................................................................................................................
..................................................................................................................................
MasalahKeperawatan:..................................................................................
PSIKOSOSIAL
Genogram : Gambarkan
Jelaskan:
..........................................................................................................................................
..........................................................................................................................................
............
Masalah Keperawatan
:.....................................................................................................
KonsepDiri
1)Gambaran diri:........................................................................................
2)Identitas :.........................................................................................
3)Peran :...........................................................................................
4)IdealDiri :.........................................................................................
5)Harga Diri :......................................................................................
MasalahKeperawatan:...................................................................................
HubunganSosial
1)Orangyangberarti:.......................................................................................
2)Peransertadalamkegiatankelompko/masyarakat:..................................
3)Hamabatan dalamberhubungan denganoanglain:.......................................
MasalahKeperawatan:.......................................................................................
Spiritual
1)Nilaidankeyakinan :.........................................................................
2)Kegiatanibadah :..........................................................................
STATUSMENTAL
Penampilan
sesuai()caraberpakaian tidaksepertibiasanya
Jelaskan :.......................................................................................
MasalahKeperawatan:............................................................................
Pembicaraan
:.........................................................................................
MasalahKeperawatan:.................................................................................
AktivitasMotorik
Jelaskan :........................................................................................
MasalahKeperawatan :................................................................................
AlamPerasaan
()Khawatir ()Gembiraberlebihan
Jelaskan :...........................................................................................
MasalahKeperawatan :..................................................................................
Afek
Jelaskan :...........................................................................................
MasalahKeperawatan:..................................................................................
Interaksiselamawawancara
MasalahKeperawatan: .....................................................................................
h.ProsesPikir
() Sirkumtansi ()Tangensial ()Kehilangan
Asosiasi()Flightofideas ( ) Blocking
Jelaskan :..............................................................................................................
MasalahKeperawatan:.......................................................................................
()Obsesi ()Fobia ()Hipokondria
()Depersonalisasi ()Ideyangterkait () Pikiran magis
Jelaskan :.................................................................................................
MasalahKeperawatan :.........................................................................
TingkatKesadaran
( )Bingung ()Sedasi
()StuporDisorientasi:
Jelaskan :.......................................................................................................
MasalahKeperawatan :..............................................................................
Memori
panjang()Gangguandaya ingat
jangkapendek
Jelaskan :.............................................................................................
MasalahKeperawatan :...................................................................................
Dayatilikdiri
()Mengingkari penyakit yangdiderita
()Menyalahkanhal–haldiluardirinya
Jelaskan :........................................................................................
MasalahKeperawatan :.............................................................................
KEBUTUHANPERSIAPANPULANG
Makan
()Bantuan minimal ()Bantuan total
.........................................................................................................................
BAB/BAK
()Bantuan minimal ()Bantuan total
....................................................................................................................................
...
Mandi
()Bantuan minimal ()Bantuan total
....................................................................................................................................
.....
Berpakain/berhias
()Bantuan minimal ()Bantuan total
....................................................................................................................................
......
Istirahatdantidur
( )Tidur sianglama :
......................................s/d..................................................
() Tidur malamlama :
......................................s/d..................................................
( ) Kegiatan sebelum/sesudah tidur :
...............................s/d.......................................
Penggunaanobat
()Bantuan minimal ()Bantuan total
....................................................................................................................................
....
Pemeliharankesehatan Ya
TidakPerawatanlanjutan ( ) ()
Kegiatandidalamrumah Ya
TidakMempersiapkanmakanan ( ) ()
Mencucipakaian ( ) ( )
Pengaturankeuangan ( ) ( )
Kegiatandi luarrumah Ya Tidak
Belanja ( ) ( )
Transportasi ( ) ( )
Lain–lain ( ) ( )
Jelaskan :................................................................................
MasalahKeperawatan:.....................................................................
MEKANISMEKOPING
Adaftif Maladaftif
Jelasakan :.....................................................................................
MasalahKeperawatan:................................................................................
MASALAHPSIKOSOSIALDANLINGKUNGAN
()Masalahdengan dukungankelompok,spesifik........................................
()Masalahberhubungandenganlingkungan,spesifik................................
()Masalahdengan pendidikan,spesifik .....................................................
()Masalahdenganpekerjaan,spesifik........................................................
()Masalah denganperumahan, spesifik .....................................................
()Masalahekonomi,spesifik.......................................................................
()Masalahdenganpelayanankesehatan,spesifik..........................................
()Masalahlainnya,spesifik.........................................................................
()Masalahdengandukunganlingkungan.........................................................
MasalahKeperawatan:........................................................................................
PENGETAHUANKURANGTENTANG
()Penyakitjiwa ( )Sistempendukung () Faktorpresipitasi
()Penyakitfisik ()Koping () Obat-obatan ()Lainnya
MasalahKeperawatan:.............................................................................................