PENGKAJIAN KEPERAWATAN KESEHATAN JIWA Web viewPENGKAJIAN KEPERAWATAN KESEHATAN JIWA Last modified by: User One

PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

Tanggal MRS : ………………..

TanggalDirawat di Ruangan : ………………..

TanggalPengkajian : ……………........

RuangRawat : …………………

I. IDENTITAS KLIEN

Nama : …………………….. (L/P)

Umur : …………….. ………

Alamat : ………………………

Pendidikan : .....................................

Agama : ....................................

Status : ....................................

Pekerjaan : ………………………

JenisKel. : ………………………

No CM : ………………………

II. ALASAN MASUK

a. DataPrimer

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b. DataSekunder

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c. KeluhanUtamaSaatPengkajian

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III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)

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IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)

1. Pernahmengalamigangguanjiwa di masalalu?

Ya

Tidak

JikaYa,Jelaskan kapan, tanda gejala/keluhan :

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2. Faktor Penyebab/Pendukung :

a. Riwayat Trauma

Usia Pelaku Korban Saksi

1. Aniayafisik ………… ………… ………… …………

2. Aniayaseksual ………… ………… ………… …………

3. Penolakan ………… ………… ………… …………

4. Kekerasandalamkeluarga ………… ………… ………… …………

5. Tindakan kriminal ………… ………… ………… …………

Jelaskan:

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DiagnosaKeperawatan :

b. Pernahmelakukanupaya / percobaan / bunuhdiri

Jelaskan:

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c. Pengalamanmasalalu yang tidakmenyenangkan (peristiwakegagalan, kematian,

perpisahan )

Jikaadajelaskan :

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d. Pernahmengalamipenyakitfisik (termasukgangguantumbuhkembang)

Ya

Tidak

JikayaJelaskan

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e. RiwayatPenggunaanNAPZA

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3. Upaya yang telah dilakukanterkaitkondisi di atas dan hasilnya :

Jelaskan:

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4. RiwayatPenyakitKeluarga

Anggotakeluarga yang gangguanjiwa ?

Ada

Tidak

Jikaada:

Hubungankeluarga:

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Gejala:

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Riwayatpengobatan:

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DiagnosaKeperawatan:

V. PENGKAJIAN PSIKOSOSIAL (Sebelumdansesudahsakit)

1. Genogram:

Jelaskan:

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2. KonsepDiri

a. Citra tubuh:

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b. Identitas:

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c. Peran:

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d. Ideal diri:

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e. Hargadiri:

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3. HubunganSosial

a. Orang yang berarti/terdekat

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b. Peransertadalamkegiatankelompok/masyarakat dan hubungan sosial

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c. Hambatandalamberhubungandengan orang lain

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4. Spiritual

a. Nilaidankeyakinan

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b. Kegiatanibadah

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VI. PEMERIKSAAAN FISIK

1. Keadaanumum

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2. Kesadaran (Kuantitas)

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3. Tanda vital:

TD : ……. mm/Hg

N :…….. x/menit

S : …….. CO

P : …….. x/menit

4. Ukur:

BB : ……. Kg

TB : ……. Cm

5. Keluhanfisik:

Jelaskan :

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VII.STATUS MENTAL

1. Penampilan (Penanpilan usia, cara perpakaian, kebersihan)

Jelaskan:

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2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter) :

Jelaskan:

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3. Aktifitasmotorik/Psikomotor

Kelambatan :

Hipokinesia,hipoaktifitas

Katalepsi

Sub stupor katatonik

Fleksibilitasserea

Jelaskan:

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Peningkatan :

Hiperkinesia,hiperaktifitas

Stereotipi

GaduhGelisahKatatonik

Mannarism

Katapleksi

Tik

Ekhopraxia

Command automatism

Grimace

Otomatisma

Negativisme

Reaksikonversi

Tremor

Verbigerasi

Berjalankaku/rigid

Kompulsif :sebutkan …………

Jelaskan:

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4. Mood dan Afek

a. Mood

Depresi Khawatir

Ketakutan Anhedonia

Euforia Kesepian

Lain lain

Jelaskan

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b. Afek

Sesuai Tidaksesuai

Tumpul/dangkal/datar Labil

Jelaskan:

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DiagnosaKeperawatan

5. InteraksiSelamaWawancara

Bermusuhan Kontakmatakurang

Tidakkooperatif Defensif

Mudahtersinggung Curiga

Jelaskan:

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DiagnosaKeperawatan

6. PersepsiSensorik

a. Halusinasi

Pendengaran

Penglihatan

Perabaan

Pengecapan

Penciuman

b. Ilusi

Ada

Tidakada

Jelaskan:

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DiagnosaKeperawatan

7. Proses Pikir

a. ArusPikir:

Koheren Inkoheren

Sirkumtansial Asosiasilonggar

tangensial Flight of Idea

Blocking Perseverasi

Logorhoe Neologisme

Clang Association Main kata kata

Afasia Lain lain…

Jelaskan:

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b. Isi Pikir

Obsesif Fobia,sebutkan…………..

Ekstasi Waham:

Fantasi o Agama

Alienasi o Somatik/hipokondria

Pikiranbunuhdiri o Kebesaran

Preokupasi o Kejar / curiga

Pikiranisolasisosial o Nihilistik

Ide yang terkait o Dosa

PikiranRendahdiri o Sisippikir

Pesimisme o Siar piker

Pikiranmagis o Kontrolpikir

Pikirancuriga Lain lain :

Jelaskan:

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c. Bentuk pikir :

Realistik

Non realistik

Dereistik

Otistik

Jelaskan:

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8. Kesadaran

Orientasi (waktu, tempat, orang)

Jelaskan:

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Meninggi

Menurun:

Kesadaranberubah

Hipnosa

Confusion

Sedasi

Stupor

Jelaskan:

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9. Memori

Gangguandayaingatjangkapanjang ( > 1 bulan)

Gangguandayaingatjangkamenengah ( 24 jam - ≤ 1 bulan)

Gangguandayaingatpendek (kurunwaktu 10 detiksampai 15 menit)

Jelaskan:

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10. Tingkat KonsentrasidanBerhitung

a. Konsentrasi

Mudahberalih

Tidakmampuberkonsentrasi

Jelaskan:

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b. Berhitung

Jelaskan:

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11. KemampuanPenilaian

Gangguanringan

Gangguanbermakna

Jelaskan :

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12. DayaTilikDiri

Mengingkaripenyakit yang diderita

Menyalahkanhal-haldiluardirinya

Jelaskan:

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VIII. KEBUTUHAN PERSIAPAN PULANG

1. Kemampuanklienmemenuhikebutuhan Perawatankesehatan,

transportasi,

tempattinggal.

Keuangandankebutuhanlainnya.

Jelaskan:

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2. KegiatanHidupSehariharia. Perawatandiri

1) MandiJelaskan :

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2) Berpakaian, berhiasdanberdandan

Jelaskan :

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3) MakanJelaskan :

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4) Toileting (BAK, BAB)Jelaskan :

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b. NutrisiBerapafrekwensimakandanfrekwensikudapandalamsehari.

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Bagaimananafsumakannya

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Bagaimanaberatbadannya.

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c. Tidur1) Istirahatdantidur

Tidursiang, lama : ____________ s/d _____________

Tidurmalam, lama : _____________ s/d _____________

Aktifitassebelum/sesudahtidur : __________ , _________

Jelaskan

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2) Gangguantidur

Insomnia Hipersomnia Parasomnia Lain lainJelaskan

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3. Kemampuan lain lain Mengantisipasikebutuhanhidup

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Membuatkeputusanberdasarkankeinginannya,

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Mengaturpenggunaanobatdanmelakukanpemeriksaankesehatannyasendiri. ....................................................................................................................................

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4. Sistem Pendukung Ya TidakKeluarga

Terapis

Teman sejawat

Kelompok sosial

Jelaskan :

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IX. MEKANISME KOPING

Jelaskan :

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X. MASALAH PSIKOSOSIALDAN LINGKUNGAN

Masalahdengandukungankelompok, spesifiknya

Jelaskan :

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Masalahberhubungandenganlingkungan, spesifiknya

Jelaskan :

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Masalahdenganpendidikan, spesifiknya

Jelaskan :

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Masalahdenganpekerjaan, spesifiknya

Jelaskan :

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Masalahdenganperumahan, spesifiknya

Jelaskan :

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Masalahdenganekonomi, spesifiknya

Jelaskan :

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Masalahdenganpelayanankesehatan, spesifiknya

Jelaskan :

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Masalahlainnya, spesifiknya

Jelaskan :

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XI. ASPEK PENGETAHUAN

Apakahklienmempunyaimasalah yang berkaitandenganpengetahuan yang

kurangtentangsuatuhal?

Bagaimanapengetahuanklien/keluargasaatinitentangpenyakit/gangguanjiwa,

perawatandanpenatalaksanaanyafaktor yang memperberatmasalah (presipitasi), obat-

obatanataulainnya.Apakahperludiberikantambahanpengetahuan yang

berkaitandenganspesifiknyamasalahtsb.

Penyakit/gangguanjiwa Penatalaksanaan

Sistempendukung Lain-lain, jelaskan

Faktorpresipitasi

Jelaskan :

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XII. ASPEK MEDIS

1. Diagnosis Medis :

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2. Diagnosa Multi Axis

Axis I : ..........................................................................................................................

Axis II :..........................................................................................................................

Axis III :..........................................................................................................................

Axis IV :..........................................................................................................................

Axis V :..........................................................................................................................

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3. Terapi Medis

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XIII. ANALISA DATA

NO DATADIAGNOSA

KEPERAWATAN

1. DS:.............................................................................................................................

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DO:.............................................................................................................................

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2. DS:.............................................................................................................................

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DO:.............................................................................................................................

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3. DS:.............................................................................................................................

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DO:.............................................................................................................................

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4. DS:.............................................................................................................................

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DO:.............................................................................................................................

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dst DS:.............................................................................................................................

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DO:.............................................................................................................................

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XIV. DAFTAR DIAGNOSA KEPERAWATAN

1. ………………………………………

2. ………………………………………

3. ………………………………………

4. ………………………………………

5. ………………………………………

6. ………………………………………

7. ………………………………………

8. dst

XV. POHON MASALAH

XVI. PRIORITAS DIAGNOSA KEPERAWATAN

1. ……………………………………………….

2. ………………………………………………

3. ………………………………………………

4. .………………………………………………

Lawang, ……………………….

Mahasiswa yang mengkaji

____________________

NIM................................

TINDAKAN KEPERAWATAN JIWA

Nama :

No CM :

:

No TindakanKeperawatan Evaluasi

Keterangan :

Cara pendokumentasian :

PadakolomTindakanKeperawatandiisi :

Tanggal& jam tindakan

Data (Tanda gejala dan kemampuan)

Diagnosa Keperawatan

Tindakan Keperawatan

KolomEvaluasi:

Evaluasisubyektif&Obyektif

Berdasarkanresponsubyektif, evaluasiobyektif

Sesuaihasilevaluasiresponsubyektif&obyektifpadafaseterminasi

A : AnalisaSesuaikemampuan Pasien

P : Planning , terdiridari P pasiendan P perawat

P pasien : berdasarkanhasilrencanatindaklanjutpadafaseterminasi

P perawat : berdasarkanhasilkontrak yang

akandatangpadafaseterminasi

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