Rencana Harian Perawat

Nama : Ruangan:
Tanggal: Jumlah pasien:

Waktu Kegiatan Keterangan

07.00

08.00

09.00

10.00

11.00

12.00

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Pembimbing Perawat

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 ASUHAN KEPERAWATAN KESEHATAN JIWA

I. PENGKAJIAN
A. IDENTITAS KLIEN:
1. Nama : (L/P)
2. Umur : tahun
3. Nomor CM :
4. Ruang Rawat :
5. Tanggal MRS :

B. ALASAN MASUK:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
..................
C. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu? Ya Tidak
2. Pengobatan sebelumnya: Berhasil Kurang Berhasil Tidak
Berhasil
3. Trauma:

Jenis Trauma Usia Pelaku Korban Saksi

Aniaya fisik
Aniaya sexual
Penolakan
Kekerasan dalam keluarga
Tindakan kriminal
Lain-lain

Jelaskan No.
1,2,3: .......................................................................................................................
..................................................................................................................................
..................................................................................................................................
 Masalah Keperawatan:.............................................................................................

4. Anggota keluarga yang gangguan jiwa? Ada Tidak ada

Bila ada : Hubungan keluarga :..........................................................................

Gejala :..........................................................................
Riw. Pengobatan :..........................................................................
Masalah Keperawatan:..............................................................................................

5. Pengalaman masa lalu yang tidak menyenangkan?

..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................
Masalah Keperawatan: .............................................................................................

D. PEMERIKSAAN FISIK
1. Tanda Vital : TD:........... mm/Hg N:............x/mt S ........... ͦ C
P ............... x/mt.
2. Ukur : BB:........... kg TB: ............ cm
Jelaskan:.........................................................................................................................
........................................................................................................................................
............
Masalah Keperawatan:....................................................................................................

E. PSIKOSOSIAL
1. Genogram: (minimal 3 generasi)
 Jelaskan:...................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................

Masalah: ...................................................................................................................

2. Konsep Diri:
a. Citra
tubuh:..................................................................................................................
............................................................................................................................
........
b. Identitas
Diri:.....................................................................................................................
............................................................................................................................
..........
c. Peran:..................................................................................................................
............................................................................................................................
............
d. Ideal
Diri:.....................................................................................................................
............................................................................................................................
............
e. Harga
Diri:.....................................................................................................................
............................................................................................................................
...........
Masalah Keperawatan:.......................................................................................

3. Hubungan Sosial
a. Orang yang
berarti:.................................................................................................................
 ............................................................................................................................
.........
b. Peran serta dalam kegiatan
kelompok/masyarakat:........................................................................................
............................................................................................................................
........
c. Hambatan dalam berhubungan dengan orang
lain:.....................................................................................................................
............................................................................................................................
Masalah Keperawatan:........................................................................................

4. Spiritual
a. Nilai dan
Keyakinan: .........................................................................................................
.........................................................................................................................
b. Kegiatan
Ibadah: ...............................................................................................................
..........................................................................................................................
Masalah Keperawatan: ............................................................................................

F. STATUS MENTAL
1. Penampilan:
Bagaimana penampilan klien dalam hal berpakaian, makan, mandi, toileting dan
pemakaian sarana dan prasarana atau instrumentasi dalam mendukung
penampilan, apakah klien:
Tidak rapi
Penggunaan pakaian tidak sesuai
Cara berpakaian tidak seperti biasa
Lain-lain,
jelaskan...................................................................................................
Masalah Keperawatan:.............................................................................................
2. Pembicaraan:
Cepat Keras Gagap Inkoherensi Apatis Lambat
Membisu Tidak mampu memulai pembicaraan
Lain-lain, jelaskan..................................................................................
Masalah Keperawatan:..............................................................................................

3. Aktivitas Motorik:
Lesu Tegang Gelisah Agitasi TIK
Grimasen
Tremor Kompulsif Lain-lain, jelaskan.......................................
Masalah Keperawatan: .............................................................................................

4. Afek dan Emosi:

a. Afek: Datar Tumpul Labil Tidak sesuai Lain-
lain Jelaskan:....................................................................................................
Masalah
Keperawatan:..............................................................................................
b. Alam Perasaan (emosi): Sedih Ketakutan Putus asa
Khawatir Gembira berlebihan Lain-lain, jelaskan............
…………………………………………………………………………….
Masalah Keperawatan:..................................................................................

5. Interaksi selama Wawancara:

Bermusuhan Tidak kooperatif Mudah tersinggung
Kontak mata kurang Defensif Curiga Lain-lain
Jelaskan:...................................................................................................................
..................................................................................................................................
Masalah Keperawatan:.........................................................................................

6. Persepsi & Sensorik:

Apakah ada gangguan: Ada Tidak ada
Halusinasi: Pendengaran Penglihatan Perabaan
Pengecapan Penghidu
 Ilusi: Ada Tidak ada Lain-lain,

jelaskan.....................................................................................................................
.......................................................................
Masalah Keperawatan:............................................................................................

7. Proses Pikir:
a. Proses pikir (arus dan bentuk pikir):
Sirkumtansial Tangensial Blocking
Kehilangan asosiasi
Flight of idea Pengulangan pembicaraan Lain-lain, jelaskan.....
..............................................................................................................................
Masalah Keperawatan:......................................................................................
b. Isi pikir:
Obsesi Phobia Hipokondria Depersonalisasi
Pikiran magis Ide terkait
Waham: Agama Somatik Kebesaran Curiga
Nihilistik Sisip pikir Siar pikir
Kontrol pikir Lain-lain, jelaskan.........................
..............................................................................................................................
Masalah Keperawatan: .........................................................................................

8. Tingkat Kesadaran:
Bingung Sedasi Stupor Lain-lain, jelaskan....................
Adakah gangguan orientasi (disorientasi): Waktu Tempat Orang
Jelaskan: .................................................................................................................
Masalah Keperawatan: ............................................................................................
9. Memori:
Gangguan daya ingat jangka panjang
Gangguan daya ingat jangka menengah
Gangguan daya ingat jangka pendek
Konfabulasi Lain-lain, jelaskan: .............................................
 Jelaskan: ..................................................................................................................
..................................................................................................................................
............
Masalah Keperawatan: ............................................................................................

10. Tingkat Konsentrasi dan Berhitung:

Mudah beralih Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhana Lain-lain, jelaskan.........................
Jelaskan: ..................................................................................................................
..................................................................................................................................
........................
Masalah Keperawatan: ..........................................................................................

11. Kemampuan Penilaian:

Gangguan ringan Gangguan bermakna Lain-lain, jelaskan..........
Jelaskan: ...............................................................................................................
..................................................................................................................................
Masalah keperawatan: ...........................................................................................
12. Daya Tilik Diri:
Mengingkari penyakit yang diderita
Menyalahkan hal-hal diluar dirinya
Lain-lain, jelaskan:...........................................................................................
Masalah Keperawatan:.............................................................................................

G. KEBUTUHAN PERENCANAAN PULANG

1. Kemampuan klien memenuhi kebutuhan:

Kemampuan memenuhi kebutuhan Ya Tidak

Makanan
Keamanan
Perawatan kesehatan
Pakaian
Transportasi
 Tempat tinggal
Keuangan
Lain-lain

Jelaskan:.................................................................................................................
......
Masalah Keperawatan:...........................................................................................

2. Kegiatan hidup sehari-hari (ADL):

a. Perawatan Diri

Kegiatan hidup sehari-hari Bantuan Total Bantuan Minimal

Mandi
Kebersihan
Makan
Buang air kecil/ BAK
Buang air besar/ BAB
Ganti pakaian
Jelaskan:.................................................................................................................
Masalah Keperawatan:...........................................................................................

b. Nutrisi:
1) Apakah anda puas dengan pola makan anda? Puas Tidak puas
Bila tidak puas,
jelaskan:....................................................................................
2) Apakah anda makan memisahkan diri? Ya Tidak
Bila ya,
jelaskan:.................................................................................................
3) Frekuensi makan sehari: ..........x (kali) dan frekuensi kudapan. ........... x
(kali).
4) Nafsu makan: meningkat menurun
berlebihan sedikit-sedikit
5) Berat badan: meningkat menurun
 Berat badan saat ini: .........kg BB terendah:........kg BB
tertinggi.......... kg.
Jelaskan:......................................................................................................

c. Tidur:
1) Apakah ada masalah tidur? Tidak Ada,
jelaskan.........................
2) Apakah merasa segar setelah bangun tidur?
Segar tidak segar,
jelaskan...........................................................
3) Apakah ada kebiasaan tidur siang?
Ya, lamanya....... jam. Tidak.
4) Apakah ada yang menolong anda mempermudah tidur?
Ada Tidak ada
Bila ada,
jelaskan:...............................................................................................
5) Tidur malam jam:......... Bangun jam:........... Rata-rata tidur malam:........
jam.
6) Apakah ada gangguan tidur? Sulit untuk tidur
Bangun terlalu pagi Somnambulisme
Terbangun saat tidur Gelisah saat tidur
Berbicara saat tidur Lain-lain,
jelaskan.....................

Jelaskan:..........................................................................................................
Masalah Keperawatan:.................................................................................
3. Kemampuan klien dalam hal-hal berikut ini:
a. Mengantisipasi kebutuhan sendiri: Ya Tidak
b. Membuat keputusan berdasarkan keinginan sendiri: Ya Tidak
c. Mengatur penggunaan obat: Ya Tidak
d. Melakukan pemeriksaan kesehatan: Ya Tidak
Jelaskan:.................................................................................................................
.......
 Masalah Keperawatan:...........................................................................................
4. Klien memiliki sistem pendukung:
a. Keluarga Ya Tidak
b. Terapis Ya Tidak
c. Teman sejawat Ya Tidak
d. Kelompok sosial Ya Tidak
Jelaskan:.................................................................................................................
Masalah Keperawatan:...........................................................................................

5. Apakah klien menikmati saat bekerja, kegiatan produktif atau hobi?

Ya/menikmati Tidak menikmati,
jelaskan............................................

H. MEKANISME KOPING

Adaptif Maladaptif
Bicara dengan orang lain Minum alkohol
Mampu menyelesaikan masalah Reaksi lambat/ berlebihan
Tekhnik relaksasi Bekerja berlebihan
Aktivitas konstruktif Menghindar
Olah raga Mencederai diri
Lain-lain Lain-lain

Jelaskan:........................................................................................................................
......................................................................................................................................
Masalah Keperawatan: ................................................................................................
I. MASALAH PSIKOSOSIAL & LINGKUNGAN
Masalah dengan dukungan kelompok, spesifiknya..............................................
..............................................................................................................................
Masalah berhubungan dengan lingkungan, spesifiknya.......................................
...............................................................................................................................
Masalah dengan pendidikan, spesifiknya.............................................................
...............................................................................................................................
Masalah dengan pekerjaan, spesifiknya...............................................................
 ..............................................................................................................................
Masalah dengan perumahan, spesifiknya.............................................................
..............................................................................................................................
Masalah dengan ekonomi, spesifiknya.................................................................
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Masalah dengan pelayanan kesehatan, spesifiknya...............................................
..............................................................................................................................
Masalah lainnya, spesifiknya.................................................................................
..............................................................................................................................
Masalah Keperawatan:.................................................................................................

J. PENGETAHUAN KURANG TENTANG:

Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang
kurang tentang suatu hal:
Penyakit/ gangguan jiwa lain-lain, jelaskan..........................................
Jelaskan:.......................................................................................................................
Masalah Keperawatan:.................................................................................................

K. ASPEK MEDIS
Diagnosa Medis :.................................................................................................
Terapi Medis :.................................................................................................
Masalah Keperawatan:.................................................................................................

L. DAFTAR MASALAH KEPERAWATAN

1. ................................................................................................................................
2. .................................................................................................................................
3. ................................................................................................................................
4. .................................................................................................................................
5. .................................................................................................................................
 M. Pohon Masalah

II. DIAGNOSA KEPERAWATAN

1. .......................................................................................................................................
2. .......................................................................................................................................
3. .......................................................................................................................................
dst.

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Perawat yang mengkaji

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III. ANALISA DATA

No
Data Senjang Masalah
Dx.
IV. RENCANA KEPERAWATAN

Nama Pasien :......................................... No. CM :.........................

Jenis Kelamin :......................................... Dx. Medis :..........................
Ruangan :......................................... Unit Keswa :..........................

Paraf &
No
Diagnosa Keperawatan Tujuan & Rencana Tindakan Nama
Dx.
Prwt
V. IMPLEMENTASI & EVALUASI

Nama Pasien :......................................... No. CM :........................

Jenis Kelamin :......................................... Dx. Medis :.........................
Ruangan :......................................... Unit Keswa :..........................

No. Paraf &

Dx Tindakan Keperawatan Evaluasi Nama