form pengkajian jiwa.docx

8/20/2019 form pengkajian jiwa.docx

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PENGKAJIAN KEPERAWATANKESEHATAN JIWA

I. IDENTITAS KLIEN Nama : …………………….. (L/P) Tanggal Dirawat :

…………………….Umur : …………….. ………Pendidikan: ...................................Agama : ...................................Status : ................................... Tanggal Pengkajian :…………….............Alamat : ……………………… Ruang Rawat :…………………….Pekerjaan : ……………………… Sum er !n"#rmasi

: ..................................$enis %el. : ………………………

N# R& : ………………………

ALASAN MASUK

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

II. RIWAYAT PENYAKIT SEKARANG dan FAKTOR PRESIPITASI………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

III. FAKTOR PREDISPOSISI RIWAYAT PENYAKIT LALU1. Perna mengalam gangg!an " #a d ma$a lal! %

'


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a Tidak

$ika a $elaskan: …………………………………………………………………………………………

………………………………………………………………………………………………………………

Diagn#sa %e*erawatan / masala+ ke*erawatan:&. Peng'(a)an $e(el!mn*a

,er+asil %urang er+asil Tidak er+asil

$elaskan: …………………………………………………………………………………………

………………………………………………………………………………………………………………

Diagn#sa %e*erawatan / masala+ ke*erawatan:

+. Perna, mengalam Pen*a- ) F $ - )erma$!- gangg!an )!m(!, -em(ang/

aTidak

,ila a jelaskan : .......................... .......................... ............................ ..........................

Diagn#sa %e*erawatan / masala+ ke*erawatan:

RIWAYAT TRAUMA

Trauma Usia Pelaku%#r an Saksi

'. Ania-a "isik ………… ………… ………… …………. Ania-a seksual ………… ………… ………… …………. Pen#lakan ………… ………… ………… …………

0. %ekerasan dalam keluarga ………… ………… ………… …………1. Tindakan kriminal ………… ………… ………… …………

$elaskan: …………………………………………………………………………………………

………………………………………………………………………………………………………………

0. Pengalaman ma$a lal! *ang ) da- men*enang-an '2P$ -'2S'$ '2 K!l)!ral danS3 r )!al/

................................................................................................................................... ...................................................................................................................................

D agn'$a Ke3era#a)an : 22222222222222222222222222222222222222222222222222222

RIWAYAT PENYAKIT KELUARGA'. Angg#ta keluarga -ang gangguan jiwa 3

Ada Tidak %alau ada : 4u ungan keluarga : ……………………………………………………………………. 5ejala : …………………………………………………………………….. Riwa-at *eng# atan : …………………………………………………………………….

Diagn#sa%e*erawatan:22222222222222222222222222222222222222222222222222222222

I4. PEMERIKSAAAN FISIK


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Tanggal 5 ……………….1. Keadaan !m!m 5

……………………………………………………………………………………………………………………………………………………………………………………………………

&. Tanda 6 )al : TD: …….mm/4g N:……..6/m S……. P……..6/m

+. U-!r5 ,, …….kg T,…….7m Turun Naik

0. Kel!,an 7 $ -5 Tidak a

$elaskan

…………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

8. Pemer -$aan F $ - 5 ,ead )' )'e/ …………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Jela$-an 5 …………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

D agn'$a Ke3era#a)an 5 22222222222222222222222222222222222222222222222

4. PENGKAJIAN PSIKOSOSIAL Se(el!m dan $e$!da, $a- )/1. Gen'gram5

Ke)erangan Gam(ar Jela$-an5

&. K'n$e3 D r

a. 9 )ra )!(!, : ……………………………………………………………………………… …………………………………………………………………………………

…………………………………………………………………………………………………………….

(. Iden) )a$ : ……………………………………………………………………………… …………………………………………………………………………………

…………………………………………………………………………………………………………….

: Peran :


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………………………………………………………………………………………………………………………………………………………………………………………………

d. Ideal d r : ……………………………………………………………………………… …………………………………………………………………………………

……………………………………………………………………………………………………………

e. Harga d r : ……………………………………………………………………………… …………………………………………………………………………………

……………………………………………………………………………………………………………

D agn'$a Ke3era#a)an 5 222222222222222222222222222222222222222222222222222222

+. H!(!ngan $'$ ala. Orang *ang (erar) ;)erde-a)5

………………………………………………………………………………………………………………………………………………………………………………………………

(. Peran $er)a dalam -eg a)an -el'm3'-;ma$*ara-a)5 …………………………………………………………………………………………

……………………………………………………………………………………………………

:. Ham(a)an dalam (er,!(!ngan dengan 'rang la n5 …………………………………………………………………………………………

……………………………………………………………………………………………………

D agn'$a Ke3era#a)an :22222222222222222222222222222222222222222222222222222

0. S3 r )!ala. N la dan -e*a- nan

………………………………………………………………………………………………………………………………………………………………………………………………

(. Keg a)an (ada, …………………………………………………………………………………………

……………………………………………………………………………………………………

Diagn#sa %e*erawatan:22222222222222222222222222222222222222222222222222222

4I. STATUS MENTAL1. Penam3 lan

Tidak ra*i Penggunaan *akaian tidak sesuai 8ara er*akaian tidak se*erti iasan-a

$elaskan: …………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………


&. Ke$adaran &enurun:

8#m*#s mentis S#*#r


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Su k#ma S#mn#lensia %#ma

&eninggi 4i*n#sa 5angguan Tidur: …………… Dis#siasi: ………………. ,eru a+

5angguan *er+atian

$elaskan :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………


+. Or en)a$

9aktu Tem*at rang

$elaskan: …………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………


0. Pem i7araan 8e*at %eras 5aga* A*atis Lam at &em isu Tidak mam*u memulai *em i7araan Lain;lain……….. $elaskan: ……………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………


8. A-) 7 )a$ m')'r -;P$ -'m')'r Kelam(a)an 5

4i*#kinesia +i*#akti"itas %atale*si

Su stu*#r katat#nik


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5aga* Stere#ti*i 5adu+ 5elisa+ %atat#nik &annarism %ata*leksi Tik =k+#*ra6ia 8#mmand aut#matism 5rima7e t#matisma Negati>isme Reaksi k#n>ersi Trem#r ?er igerasi ,erjalan kaku/rigid %#m*ulsi" : se utkan ………………….

Jela$-an 5………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

D agn'$aKe3era#a)an 5 22222222222222222222222222222222222222222222222222222

. Per$e3$ ? Sen$'r -Hal!$ na$

Pendengaran Pengli+atan Pera aan Penge7a*an Pen7iuman ……………..

Il!$ Ada Tidak ada

De3er$'nal $a$ Ada

Tid k d


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Dereal $a$ Ada Tidak ada

Gangg!an $'ma)'$en$'r - 3ada rea-$ -'n6er$ Ada Tidak ada

Jela$-an5 ……………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………

D agn'$a Ke3era#a)an 5 2222222222222222222222222222222222222222222222

@. Pr'$e$ P - ra. Ar!$ P - r

%#+eren!nk#+erenSirkumstansial

Ne#l#gismeTangensialL#g#rea%e+ilangan as#siasi,i7ara lam at


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%ejar / 7uriga Ni+ilistik D#sa

Sisi* *ikir Siar *iker %#ntr#l *ikir

Lain @ lain……………….

:. en)!- P - rRealistik

N#n Realistik Dereistik tistik

Jela$-an5 ……………………………………………………………………………………………………

……………………………………………………………………………………………………………

…………………………………………………………………………………………………………………D agn'$a Ke3era#a)an 5 22222222222222222222222222222222222222222222222222

. In)era-$ $elama #a#an:ara ,ermusu+an Tidak k##*erati" &uda+ tersinggung %#ntak mata kurang De"ensi" 8uriga

Jela$-an5 ……………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………

D agn'$a Ke3era#a)an 5 2222222222222222222222222222222222222222222222

1B. Mem'r 5angguan da-a ingat jangka *anjang ( ' ulan) 5angguan da-a ingat jangka *endek ( ' +ari @ ' ulan) 5angguan da-a ingat saat ini ( B 0 jam) Amnesia Paramnesia:

%#n"a ulasi Deja>u $amais>u


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Tidak mam*u er+itung seder+ana Jela$-an5

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

D agn'$a Ke3era#a)an 5

222222222222222222222222222222222222222222222222222222222

1&. Kemam3!an 3en la an 5angguan ringan 5angguan ermakna

Jela$-an5 ……………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………

D agn'$a Ke3era#a)an 5 22222222222222222222222222222222222222222222222222222222

1+. Da*a ) l - d r &engingkari *en-akit -ang diderita &en-ala+kan +al;+al diluar dirin-a

Jela$-an5 ……………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………

D agn'$a Ke3era#a)an 5 222222222222222222222222222222222222222222222222222222222

4II. KE UTUHAN PERSIAPAN PULANG1. Ma-an

,antuan &inimal ,antuan t#tal $elaskan :

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

&. A ; AK ,antuan minimal

,antuan t#tal $elaskan : …………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………

+. Mand ,antuan minimal ,antuan t#tal $elaskan :

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

0. er3a-a an;(er, a$ ,antuan &inimal ,antuan t#tal $elaskan


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:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

8. I$) ra,a) dan ) d!r Tidur Siang Lama : 222222222222 s/d 2222222222222

Tidur &alam Lama : 2222222222222 s/d 2222222222222 Akti"itas se elum/sesuda+ tidur : 2222222222 222222222 $elaskan:

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………


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MASALAH PSIKOSOSIAL DAN LINGKUNGAN &asala+ dengan dukungan kel#m*#k s*esi"ikn-a ……………………………………………...

…………………………………………………………………………………………………… &asala+ er+u ungan dengan lingkungan s*esi"ikn-a ……………….………………………...

…………………………………………………………………………………………………… &asala+ dengan *endidikan s*esi"ikn-a ………………………………………………………..

…………………………………………………………………………………………………… &asala+ dengan *ekerjaan s*esi"ikn-a ………………………………………………………….

…………………………………………………………………………………………………… &asala+ dengan *eruma+an s*esi"ikn-a ………………………………………………………..

…………………………………………………………………………………………………… &asala+ dengan ek#n#mi s*esi"ikn-a …………………………………………………………..

…………………………………………………………………………………………………… &asala+ dengan *ela-anan kese+atan s*esi"ikn-a ……………………………………………...

…………………………………………………………………………………………………… &asala+ lainn-a s*esi"ikn-a …………………………………………………………………….

……………………………………………………………………………………………………

Diagn#sa %e*erawatan :22222222222222222222222222222222222222222222222222222222

4III. PENGETAHUAN KURANG TENTANG A*aka+ klien mem*un-ai masala+ -ang erkaitan dengan *engeta+uan -ang kurang tentang

suatu +al3 Pen-akit/gangguan jiwa Sistem *endukung


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$elaskan: ………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Diagn#sa %e*erawatan: 2222222222222222222222222222222222222222222222222222222

IC. ASPEK MEDIS Diagn#sis medik: …………………………………………………………………………………… Tera*i medik: ……………………………………………………………………………………. .....

…………………………………………………………………………………………………….……………………………………………………………………………………………………….

ANALISA DATA

NO DATA DIAGNOSA KEPERAWATAN

1. DS5

DO5

C. DAFTAR DIAGNOSA KEPERAWATAN1. ..&. ..+. ..0. ..

8. ... ..@. ..

. ...1B. d$)

CI. PRIORITAS DIAGNOSA KEPERAWATAN1. ..&. ..+. ..

&alang ……………………….


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Perawat -ang mengkaji

22222222222222222222222222222 2

N!&/N!R&: …………………….


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JURUSAN KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA

LAPORAN PENDAHULUAN


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ORIENTASI1. Salam Terapeutik:

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2. Evaluasi !alidasi: ..................................................................................................................................

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3. Kontrak: Topik" waktu" dan tempat

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KERJA : #angkah$#angkah Tindakan keperawatan ..................................................................................................................................

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TERMINASI :1. Evaluasi respon klien terhadap tindakan keperawatan:

Su%&ekti': ..................................................................................................................................

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(%&ekti': ..................................................................................................................................

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2. Tindak lanjut klien )apa &ang perlu dilatih klien sesuai dengan hasil tindakan &ang telahdilakukan*:

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3. Kontrak &ang akan datang )Topik" waktu" dan tempat*:

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RENCANA ASUHAN KEPERAWATAN

Nama Klien N!. Re". Tan

""al

N! Dia"n!#a

Ke$e%a&a'an T()(an K%i'e%ia

S'an*a%' In'e%+en#i Ra#i!nal

TT


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IMPLEMENTASI DAN EVALUASI KEPERAWATAN KESEHATAN JIWA

+ama : ,,,,,,,,,,,,,,,,, -uangan : ,,,,,,,,,,,,,,,,,,,,, - +o. : ,,,,,,,,,,,,,,,,,

NO

D,

Tan""al -

Jam

IMPLEMENTASI KEPERAWATAN EVALUASI


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ANALISA PROSES INTERAKSI

/nisial klien : ................................................................... +ama ahasiswa: ...................................................................

Status interaksi perawat$klien : ................................................................... Tanggal: ...................................................................

#ingkungan : ................................................................... 0am: ...................................................................

Deskripsi klien : ................................................................... angsal: ................................................................... Tujuan )%erorientasi pada klien : ...................................................................

KOMUNIKASIVERBAL

KOMUNIKASI NONVERBAL

ANALISA BERPUSAT PADA PERAWAT

ANALISA BERPUSAT PADA KLIEN

RASIONAL

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-ekomendasi :.............................................................................................................................................................................................................


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