format pengkajian jiwa (odgj & resiko)
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Format Pengkajian Jiwa (ODGJ & Resiko)TRANSCRIPT
PROGRAM STUDI ILMU KEPERAWATAN
PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
LAPORAN PENDAHULUAN
STRATEGI PELAKSANAAN
TINDAKAN KEPERAWATAN HARI KE
A. PROSES KEPERAWATAN
1. Kondisi klien:
Ramah, menjabat tangan perawat,2. Diagnosa keperawatan:
Halusinasi3. Tujuan khusus:
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4. Tindakan keperawatan:
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B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN KEPERAWATAN
ORIENTASI
1. Salam Terapeutik:
Perawat mengucapakan salam kepada pasien2. Evaluasi/ Validasi:
Perawat menanyakan kabar pasien3. Kontrak: Topik, waktu, dan tempat
Topik : Waktu :
Tempat :
KERJA: Langkah-Langkah Tindakan keperawatan
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TERMINASI:
1. Evaluasi respon klien terhadap tindakan keperawatan:
Subyektif:
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Obyektif:
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2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang telah dilakukan):
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3. Kontrak yang akan datang (Topik, waktu, dan tempat):
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PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
PENGKAJIAN KEPERAWATAN
KESEHATAN JIWA
RUANG RAWAT:
TANGGAL DIRAWAT:
I. IDENTITAS KLIEN
Inisial:___________________________(L/P)Tanggal Pengkajian :_____________________
Umur:___________________________RM No.
:_____________________
Alamat:___________________________
Pekerjaan:___________________________
Informan:___________________________
II. ALASAN MASUK
______________________________________________________________________________________________________________________________________________________________________
III. FAKTOR PRESIPITASI/ RIWAYAT PENYAKIT SEKARANG
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
IV. FAKTOR PREDISPOSISI
RIWAYAT PENYAKIT LALU
1. Pernah mengalami gangguan jiwa di masa lalu? FORMCHECKBOX ya FORMCHECKBOX tidak
Bila ya jelaskan___________________________________________________________________
2. Pengobatan sebelumnya FORMCHECKBOX Berhasil FORMCHECKBOX Kurang Berhasil FORMCHECKBOX Tidak Berhasil
3. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang) FORMCHECKBOX ya
FORMCHECKBOX tidak
Bila ya jelaskan___________________________________________________________________
RIWAYAT PSIKOSOSIAL
Pelaku/ usia
Korban/ usia
Saksi/ usia
1. Aniaya fisik
2. Aniaya seksual
3. Penolakan
4. Kekerasan dalam keluarga
5. Tindakan kriminal
Jelaskan:___________________________________________________________________
___________________________________________________________________
6. Pengalaman masa lalu lain yang tidak menyenangkan (bio, psiko, sosio, kultural, spiritual):
______________________________________________________________________________________________________________________________________________________________
Masalah keperawatan:____________________________________________________________
7. Kesan Kepribadian klien: FORMCHECKBOX extrovert FORMCHECKBOX introvert FORMCHECKBOX lain-lain:__________________
RIWAYAT PENYAKIT KELUARGA
1. Adakah anggota keluarga yang mengalami gangguan jiwa? FORMCHECKBOX ya
FORMCHECKBOX tidak
Hubungan keluarga
Gejala
Riwayat Pengobatan/ perawatan
_________________________________________________ ___________________________
_______________________ __________________________ ___________________________
Masalah keperawatan:____________________________________________________________
V. STATUS MENTAL
1. Penampilan
FORMCHECKBOX tidak rapi
FORMCHECKBOX penggunaan pakaian
FORMCHECKBOX Cara berpakaian tidak seperti
tidak sesuai
biasanya
Jelaskan: __________________________________________________________________
Masalah keperawatan : ____________________________________________________________
2. Kesadaran
Kwantitatif/ penurunan kesadaran]
FORMCHECKBOX compos mentis
FORMCHECKBOX apatis/ sedasi
FORMCHECKBOX somnolensia
FORMCHECKBOX sopor
FORMCHECKBOX subkoma
FORMCHECKBOX koma
Kwalitatif
FORMCHECKBOX tidak berubah
FORMCHECKBOX berubah
FORMCHECKBOX meninggi
FORMCHECKBOX gangguan tidur: sebutkan______________________________
FORMCHECKBOX hipnosa
FORMCHECKBOX disosiasi: sebutkan____________________________________
3. Disorientasi
FORMCHECKBOX waktu
FORMCHECKBOX tempat
FORMCHECKBOX orang
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
4. Aktivitas Motorik/ Psikomotor
Kelambatan:
FORMCHECKBOX hipokinesia, hipoaktivitas
FORMCHECKBOX sub stupor katatonik
FORMCHECKBOX katalepsi
FORMCHECKBOX flexibilitas serea
Peningkatan:
FORMCHECKBOX hiperkinesia, hiperaktivitas
FORMCHECKBOX gaduh gelisah katatonik
FORMCHECKBOX TIK
FORMCHECKBOX grimase
FORMCHECKBOX tremor
FORMCHECKBOX gagap
FORMCHECKBOX stereotipi
FORMCHECKBOX mannarism
FORMCHECKBOX katalepsi
FORMCHECKBOX akhopraxia
FORMCHECKBOX command automatism FORMCHECKBOX atomatisma
FORMCHECKBOX nagativisme
FORMCHECKBOX reaksi konversi FORMCHECKBOX verbigerasi
FORMCHECKBOX berjalan kaku/ rigit FORMCHECKBOX kompulsif
FORMCHECKBOX lain-2 sebutkan
5. Afek/ Emosi
FORMCHECKBOX adequat
FORMCHECKBOX tumpul
FORMCHECKBOX dangkal/ datar FORMCHECKBOX labil
FORMCHECKBOX inadequat
FORMCHECKBOX anhedonia
FORMCHECKBOX marasa kesepian FORMCHECKBOX eforia
FORMCHECKBOX ambivalen
FORMCHECKBOX apati
FORMCHECKBOX marah
FORMCHECKBOX depresif/ sedih FORMCHECKBOX cemas: FORMCHECKBOX ringan
FORMCHECKBOX sedang
FORMCHECKBOX berat
FORMCHECKBOX panik
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
6. Persepsi
FORMCHECKBOX halusinasi
FORMCHECKBOX ilusi
FORMCHECKBOX depersonalisasi FORMCHECKBOX derealisasi
Macam Halusinasi
FORMCHECKBOX pendengaran
FORMCHECKBOX penglihatan
FORMCHECKBOX perabaan
FORMCHECKBOX pengecapan
FORMCHECKBOX penghidu/ pembauan FORMCHECKBOX lain-lain, sebutkan...................
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
7. Proses Pikir
Arus Pikir
FORMCHECKBOX koheren
FORMCHECKBOX inkoheren
FORMCHECKBOX asosiasi longgar
FORMCHECKBOX fligt of ideas
FORMCHECKBOX blocking
FORMCHECKBOX pengulangan pembicaraan/ persevarasi
FORMCHECKBOX tangansial
FORMCHECKBOX sirkumstansiality FORMCHECKBOX logorea
FORMCHECKBOX neologisme FORMCHECKBOX bicara lambat FORMCHECKBOX bicara cepat FORMCHECKBOX irelevansi
FORMCHECKBOX main kata-kata FORMCHECKBOX afasi FORMCHECKBOX assosiasi bunyi FORMCHECKBOX lain2 sebutkan..
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
Isi Pikir
FORMCHECKBOX obsesif
FORMCHECKBOX ekstasi
FORMCHECKBOX fantasi
FORMCHECKBOX bunuh diri
FORMCHECKBOX ideas of reference
FORMCHECKBOX pikiran magis
FORMCHECKBOX alienasi
FORMCHECKBOX isolaso sosial
FORMCHECKBOX rendah diri
FORMCHECKBOX preokupasi
FORMCHECKBOX pesimisme
FORMCHECKBOX fobia sebutkan.........................
FORMCHECKBOX waham: sebutkan jenisnya
FORMCHECKBOX agama FORMCHECKBOX somatik, hipokondrik FORMCHECKBOX kebesaran FORMCHECKBOX curiga
FORMCHECKBOX nihilistik FORMCHECKBOX sisip pikir FORMCHECKBOX siar pikir
FORMCHECKBOX kontrol pikir
FORMCHECKBOX kejaran
FORMCHECKBOX dosa
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
Bentuk Pikir
FORMCHECKBOX realistik
FORMCHECKBOX nonrealistik
FORMCHECKBOX autistik
FORMCHECKBOX dereistik
8. Memori
FORMCHECKBOX gangguan daya ingat jangka panjang FORMCHECKBOX gangguan daya ingat jangka pendek
FORMCHECKBOX gangguan daya ingat saat ini
FORMCHECKBOX amnesia, sebutkan.........................
FORMCHECKBOX paramnesia, sebutkan jenisnya........................................................
FORMCHECKBOX hipermnesia, sebutkan ...................................................................
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
9. Tingkat Konsentrasi dan Berhitung
FORMCHECKBOX mudah beralih FORMCHECKBOX tidak mampu berkonsentrasi FORMCHECKBOX tidak mampu berhitung sederhana
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
10. Kemampuan Penilaian
FORMCHECKBOX gangguan ringan
FORMCHECKBOX gangguan bermakna
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________11. Daya Tilik Diri/ Insight
FORMCHECKBOX mengingkari penyakit yang diderita
FORMCHECKBOX menyalahkan hal-hal diluar dirinya
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________12. Interaksi selama Wawancara
FORMCHECKBOX bermusuhan
FORMCHECKBOX tidak kooperatif
FORMCHECKBOX mudah tersinggung
FORMCHECKBOX kontak mata kurang FORMCHECKBOX defensif
FORMCHECKBOX curiga
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________VI. FISIK
1. Keadaan umum ____________________________________________________________________
_________________________________________________________________________________
2. Tanda vital: TD:___________N:___________
S:_____________P:_______
3. UKur:
TB:___________BB:__________
FORMCHECKBOX turun
FORMCHECKBOX naik4. Keluhan fisik:
FORMCHECKBOX tidak
FORMCHECKBOX ya jelaskan...............................
_________________________________________________________________________________
5. Pemeriksaan fisik:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Jelaskan:__________________________________________________________________________
Masalah keperawatan : _______________________________________________________________
VII. PENGKAJIAN PSIKOSOSIAL (sebelum dan sesudah sakit)
1. Konsep Diri
a. Citra tubuh:___________________________________________________________________
___________________________________________________________________
b. Identitas:___________________________________________________________________
___________________________________________________________________
c. Peran
:___________________________________________________________________
___________________________________________________________________
d. Ideal diri:___________________________________________________________________
___________________________________________________________________
e. Harga diri:___________________________________________________________________
___________________________________________________________________
Masalah keperawatan : _______________________________________________________________
2. Genogram
3. Hubungan Sosial
a. Hubungan terdekat:
____________________________________________________________________________________________________________________________________________________________
b. Peran serta dalam kelompok/ masyarakat
____________________________________________________________________________________________________________________________________________________________
c. Hambatan dalam berhubungan dengan orang lain
____________________________________________________________________________________________________________________________________________________________
Masalah keperawatan : ______________________________________________________________4. Spiritual dan kultural
a. Nilai dan keyakinan
____________________________________________________________________________________________________________________________________________________________
b. Konflik nilai/ keyakinan/ budaya
____________________________________________________________________________________________________________________________________________________________
c. Kegiatan ibadah
____________________________________________________________________________________________________________________________________________________________
Masalah keperawatan:_______________________________________________________________
VIII. AKTIVITAS SEHARI-HARI (ADL)
1.Makan
FORMCHECKBOX Bantuan minimal
FORMCHECKBOX Sebagian
FORMCHECKBOX Bantuan total
2.BAB/BAK
FORMCHECKBOX Bantuan minimal
FORMCHECKBOX Sebagian
FORMCHECKBOX Bantuan total
3.Mandi
FORMCHECKBOX Bantuan minimal
FORMCHECKBOX Sebagian
FORMCHECKBOX Bantuan total
4.Berpakaian/berhias
FORMCHECKBOX Bantuan minimal
FORMCHECKBOX Sebagian
FORMCHECKBOX Bantuan total
5.Istirahat dan tidur
FORMCHECKBOX Tidur siang lama: ______________________ s/d _________________________
FORMCHECKBOX Tidur malam lama: ______________________ s/d _________________________
FORMCHECKBOX Aktivitas sebelum / sedudah tidur : _____________________ s/d _____________________
6.Pengginaan obat
FORMCHECKBOX Bantuan minimal
FORMCHECKBOX Sebagian
FORMCHECKBOX Bantuan total
7.Pemeliharaan kesehatan
Perawatan Lanjutan
FORMCHECKBOX Ya
FORMCHECKBOX Tidak
Sistem pendukung
FORMCHECKBOX Ya
FORMCHECKBOX Tidak
8. Aktivitas di dalam rumah
Mempersiapkan makanan
FORMCHECKBOX Ya
FORMCHECKBOX Tidak
Menjaga kerapihan rumah
FORMCHECKBOX Ya
FORMCHECKBOX Tidak
Mencuci pakaian
FORMCHECKBOX Ya
FORMCHECKBOX Tidak
Pengaturan keuangan
FORMCHECKBOX Ya
FORMCHECKBOX Tidak
9. Aktivitas di luar rumah
Belanja
FORMCHECKBOX Ya
FORMCHECKBOX Tidak
Transportasi
FORMCHECKBOX Ya
FORMCHECKBOX Tidak
Lain-lain
FORMCHECKBOX Ya
FORMCHECKBOX Tidak
Jelaskan:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
IX. MEKANISME KOPING
Adatif
Maladaptif
FORMCHECKBOX Bicara dengan orang lain
FORMCHECKBOX Minum Alkohol
FORMCHECKBOX Mampu menyelesaikan masalah
FORMCHECKBOX Reaksi lambat / berlebih
FORMCHECKBOX Teknik relokasi
FORMCHECKBOX Bekerja berlebihan
FORMCHECKBOX Aktivitas konstruktif
FORMCHECKBOX Menghindar
FORMCHECKBOX Olah raga
FORMCHECKBOX Mencederai diri
FORMCHECKBOX Lainnya ......................
FORMCHECKBOX Lainnya ......................
Masalah keperawatan : ______________________________________________________________
X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
FORMCHECKBOX Masalah dengan dukungan kelompok, uraikan ______________________________________________________________________________
FORMCHECKBOX Masalah berhubungan dengan lingkungan, uraikan ______________________________________________________________________________
FORMCHECKBOX Masalah dengan pendidikan, uraikan ______________________________________________________________________________
FORMCHECKBOX Masalah dengan pekerjaan, uraikan ______________________________________________________________________________
FORMCHECKBOX Masalah dengan perumahan, uraikan ______________________________________________________________________________
FORMCHECKBOX Masalah dengan ekonomi, uraikan ______________________________________________________________________________
FORMCHECKBOX Masalah dengan pelayanan kesehatan, uraikan ______________________________________________________________________________
FORMCHECKBOX Masalah lainnya, uraikan ______________________________________________________________________________
Masalah keperawatan : ______________________________________________________________
XI. KURANG PENGETAHUAN TENTANG
FORMCHECKBOX Penyakit jiwa
FORMCHECKBOX Sistem pendukung
FORMCHECKBOX Faktor presiptasi
FORMCHECKBOX Penyakit fisik
FORMCHECKBOX Koping
FORMCHECKBOX Obat-obatan
FORMCHECKBOX Lainnya _______________________________________________________________________
Masalah keperawatan : ______________________________________________________________
XII. ASPEK MEDIK
Diagnosa medik: _________________________________________________________________
Terapi medik: _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
XIII. DAFTAR MASALAH KEPERAWATAN
____________________________
_____________________________
____________________________
_____________________________
____________________________
_____________________________
____________________________
_____________________________
____________________________
_____________________________
XIV. ANALISA DATA
NoDATAMASALAH
XV. POHON MASALAH
XVI. DIAGNOSA KEPERAWATAN
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________
Mahasiswa
______________________________
PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
DAFTAR DIAGNOSA KEPERAWATAN
(Berdasarkan prioritas)
Ruang
:
Nama Pasien:
No. Register:
No. DxTANGGAL MUNCULDIAGNOSA KEPERAWATANTANGGAL TERATASITANDA TANGAN
PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
IMPLEMENTASI DAN EVALUASI
KEPERAWATAN KESEHATAN JIWA
Nama : _________________Ruangan : _____________________RM No. : _________________
NO
DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI
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