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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
$elaskan: …………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………
Diagn#sa%e*erawatan:22222222222222222222222222222222222222222222222222222222
&. Ke$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
$elaskan :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Diagn#sa%e*erawatan:22222222222222222222222222222222222222222222222222222222
+. Or en)a$
9aktu Tem*at rang
$elaskan: …………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………
Diagn#sa%e*erawatan:22222222222222222222222222222222222222222222222222222222
0. Pem i7araan 8e*at %eras 5aga* A*atis Lam at &em isu Tidak mam*u memulai *em i7araan Lain;lain……….. $elaskan: ……………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………
Diagn#sa%e*erawatan:22222222222222222222222222222222222222222222222222222222
8. A-) 7 )a$ 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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JURUSAN KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
RENCANA ASUHAN KEPERAWATAN
Nama Klien N!. Re". Tan
""al
N! Dia"n!#a
Ke$e%a&a'an T()(an K%i'e%ia
S'an*a%' In'e%+en#i Ra#i!nal
TT
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JURUSAN KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
IMPLEMENTASI DAN EVALUASI KEPERAWATAN KESEHATAN JIWA
+ama : ,,,,,,,,,,,,,,,,, -uangan : ,,,,,,,,,,,,,,,,,,,,, - +o. : ,,,,,,,,,,,,,,,,,
NO
D,
Tan""al -
Jam
IMPLEMENTASI KEPERAWATAN EVALUASI
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JURUSAN KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
ANALISA PROSES INTERAKSI
/nisial klien : ................................................................... +ama ahasiswa: ...................................................................
Status interaksi perawat$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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