FORMAT PENGKAJIAN ASUHAN KEPERAWATAN JIWA STIKES HANG TUAH SURABAYA

Nama mahasiswa NIM Ruangan Pengkajian diambil Diagnosa medis

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IDENTITAS KLIEN No. RM : Nama Inisial Umur : : L/P : .......... tahun

II. ALASAN MASUK ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... III. FAKTOR PREDISPOSISI 1. Pernah mengalami gangguan jiwa di masa lalu? a. Ya b. Tidak 2. Pengobatan sebelumnya? a. Berhasil b. Kurang berhasil c. Tidak berhasil 3. Faktor : Aniaya fisik a. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahun c. Saksi : ..................................................................................... Usia : ............. tahun Aniaya seksual a. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahun c. Saksi : ..................................................................................... Usia : ............. tahun Penolakan a. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahun c. Saksi : ..................................................................................... Usia : ............. tahun Kekerasan dalam rumah tangga a. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahun c. Saksi : ..................................................................................... Usia : ............. tahun Tindakan kriminal a. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahun c. Saksi : ..................................................................................... Usia : ............. tahun Jelaskan no. 1, 2, 3 ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

Masalah keperawatan ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

4. Adakah anggota keluarga yang mengalami gangguan jiwa? a. Ya b. Tidak Bila ada isi dibawah ini : Hubungan keluarga Gejala a. .............................. a. .............................. b. .............................. b. ..............................

Riwayat pengobatan/perawatan a. .............................. b. ..............................

Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 5. Pengalaman masa lalu yang tidak menyenangkan ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... IV. PENGKAJIAN FISIK 1. Tanda Vital TD : mm/hg N : x/menit S : C P : x/menit 2. Ukur tubuh TB : cm BB : kg 3. Keluhan Fisik a. Ya b. Tidak Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah Keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................

V. PSIKOSOSIAL 1. Genogram :

Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................

2. Konsep diri a. Gambaran diri : ................................................................................................................................................... ................................................................................................................................................... b. Identitas : ................................................................................................................................................... ................................................................................................................................................... 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 : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... VI. STATUS MENTAL 1. Penampilan a. Tidak rapi c. Cara berpakaian tidak seperti biasanya b. Penggunaan pakaian tidak sesuai Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................

2. Pembicaraan a. Cepat e. Apatis h. Tidak mampu b. Keras f. Lambat memulai c. Gagap g. Membisu pembicaraan d. Inkoheren Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 3. Aktivitas motorik a. Lesu c. Gelisah e. TIK g. Tremor b. Tegang d. Agitasi f. Grimasen h. Kompulsif Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 4. Alam perasaan a. Sedih c. Gembira e. Khawatir b. Putus asa d. Ketakutan f. Berlebihan Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 5. Afek a. Datar b. Tumpul c. Labil d. Tidak sesuai Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 6. Interaksi selama wawancara a. Bermusuhan c. Mudah tersinggung e. Defensif b. Tidak kooperatif d. Kontak mata (-) f. Curiga Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................

7. Persepsi a. Pendengaran c. Perabaan e. Penghidungan b. Penglihatan d. Pengecapan Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 8. Proses pikir a. Sirkumtansial d. Flight of idea f. Pengulangan b. Tangensial e. Blocking pembicaraan c. Kehilangan asosiasi /persevarasi Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 9. Isi pikiran a. Obsesi c. Hipokondria e. Ide yang terkait b. Fobia d. Depersonalisasi f. Pikiran magis Waham a. Agama d. Curiga g. Siar pikir b. Somatik e. Nihilistic h. Kontrol pikir c. Kebesaran f. Sisip pikir Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 10. Tingkat kesadaran a. Bingung b. Sedasi c. Stupor Disorientasi a. Waktu b. Tempat c. Orang Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 11. Memori a. Gangguan daya ingat jangka panjang c. Gangguan daya ingat jangka pendek b. Gangguan daya ingat saat ini d. Konfabulasi Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................

Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 12. Tingkat konsentrasi dan berhitung a. Mudah beralih c. Tidak mampu konsentrasi sederhana b. Tidak mampu berhitung Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 13. Kemampuan penilaian a. Gangguan ringan b. Gangguan bermakna Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 14. Daya tilik diri a. Mengingkari penyakit yang di derita b. Menyalahkan hal-hal di luar dirinya Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... VII. KEBUTUHAN PERSIAPAN PULANG 1. Makan a. Bantuan minimal b. Bantuan total 2. BAB / BAK a. Bantuan minimal b. Bantuan total Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 3. Mandi a. Bantuan minimal b. Bantuan total 4. Berpakaian / berhias a. Bantuan minimal b. Bantuan total Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................

5. Istirahat dan tidur Tidur siang lama : ................ s/d ..................... Tidur malam lama : ................ s/d ..................... Kegiatan sebelum/sesudah tidur : ......................................................................................................................................................... ......................................................................................................................................................... 6. Penggunaan obat a. Bantuan minimal b. Bantuan total 7. Pemeliharaan kesehatan Perawatan lanjutan a. Ya b. Tidak Perawatan pendukung a. Ya b. Tidak 8. Kegiatan di dalam rumah Mempersiapkan makanan a. Ya b. Tidak Menjaga kerapihan rumah a. Ya b. Tidak Mencuci pakaian a. Ya b. Tidak Pengaturan keuangan a. Ya b. Tidak 9. Kegiatan di luar rumah Belanja a. Ya b. Tidak Transportasi a. Ya b. Tidak Lain-lain a. Ya b. Tidak Jelaskan : ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... VIII. MEKANISME KOPING Adaptif 1. Bicara dengan orang lain 2. Mampu menyelesaikan masalah 3. Teknik relaksasi 4. Aktivitas konstruktif 5. Olah raga Lainnya .......................................................................... Maladaptif 1. Minum alkohol 2. Reaksi lambat / berlebih 3. Bekerja berlebihan 4. Menghindar 5. Mencederai diri Lainnya ..........................................................................

Masalah keperawatan : ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN 1. Masalah dengan dukungan kelompok, spesifik ......................................................................................................................................................... ......................................................................................................................................................... 2. Masalah berhubungan dengan lingkungan, spesifik ......................................................................................................................................................... ......................................................................................................................................................... 3. Masalah dengan pendidikan, spesifik ......................................................................................................................................................... ......................................................................................................................................................... 4. Masalah dengan pekerjaan, spesifik ......................................................................................................................................................... .........................................................................................................................................................

5. Masalah dengan perumahan, spesifik ......................................................................................................................................................... ......................................................................................................................................................... 6. Masalah ekonomi, spesifik ......................................................................................................................................................... ......................................................................................................................................................... 7. Masalah dengan pelayanan kesehatan, spesifik ......................................................................................................................................................... ......................................................................................................................................................... 8. Masalah lainnya, spesifik ......................................................................................................................................................... ......................................................................................................................................................... Masalah keperawatan : ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... X. PENGETAHUAN KURANG TENTANG 1. Penyakit jiwa 3. Faktor presipitasi 5. Koping 2. Sistem pendukung 4. Penyakit fisik 6. Obat-obatan Lainnya ............................................................................................................................................................... Masalah keperawatan : ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... XI. ASPEK MEDIK 1. Diagnosa medik : ........................................................................................................................ 2. Terapi medik : ........................................................................................................................ ........................................................................................................................ XII. DAFTAR DIAGNOSA KEPERAWATAN ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ...............................................................................................................................................................

Surabaya, .....................

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POHON MASALAH Akibat

Core problem

Penyebab

ANALISA DATA Nama klien Umur No. : .............................................. : .............................................. Data (Symptom) Ruangan/kamar : .............................................. No. RM : .............................................. Masalah (Problem)

Penyebab (Etiologi)

INTERVENSI KEPERAWATAN No Tanggal Diagnosa Keperawatan Tujuan Kriteria evaluasi Intervensi

IMPLEMENTASI DAN EVALUASI No Tanggal/jam Implementasi Evaluasi Paraf

STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN Nama Klien Umur Masalah : : : Pertemuan ke- : ............................................... Dx. Medis : ...............................................

A. Proses Keperawatan 1. Kondisi pasien ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 2. Masalah/diagnosis keperawatan ......................................................................................................................................................... ......................................................................................................................................................... 3. Tujuan keperawatan ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... B. Strategi Komunikasi 1. Orientasi a. Salam terapeutik ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... b. Evaluasi validasi ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... c. Kontrak 1) Topik ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. 2) Waktu ............................................................................................................................................. ............................................................................................................................................. 3) Tempat ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. 2. Kerja ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................

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3. Terminasi a. Evaluasi subjektif (wawancara/sanjungan) ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... b. Evaluasi objektik (wawancara dan observasi) ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... c. Tindak lanjut ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... d. Kontrak yang akan datang 1) Topik ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. 2) Waktu ............................................................................................................................................. ............................................................................................................................................. 3) Tempat ............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................

Mahasiswa,

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ANALISA PROSES INTERAKSI Inisial klien Status interaksi P K Lingkungan Deskripsi Klien Tujuan interaksiDeskripsi Klien :

: : : : :

Nama Mahasiswa Tanggal Waktu Tempat

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.................................................................................................................................................................................................................................................................................. .................................................................................................................................................................................................................................................................................. ..................................................................................................................................................................................................................................................................................Lingkungan :

.................................................................................................................................................................................................................................................................................. .................................................................................................................................................................................................................................................................................. ..................................................................................................................................................................................................................................................................................Komunikasi Verbal Komunikasi Non - Verbal Analisa Berpusat Pada Perawat Analisa Berpusat Pada Klien Rasional

Komunikasi Verbal

Komunikasi Non - Verbal

Analisa Berpusat Pada Perawat

Analisa Berpusat Pada Klien

Rasional

Kesan Perawat :

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Mahasiswa,

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