Format Askep Jiwa

FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN JIWA

STIKES HANG TUAH SURABAYA

Nama mahasiswa : ..................................................................................................................................NIM : ..................................................................................................................................Ruangan : ..................................................................................................................................Pengkajian diambil : ..................................................................................................................................Diagnosa medis : ..................................................................................................................................

I. IDENTITAS KLIENNo. RM : .............................................................................................................................................Nama : .............................................................................................................................................Inisial : L / PUmur : .......... tahun

II. ALASAN MASUK.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

III. FAKTOR PREDISPOSISI1. Pernah mengalami gangguan jiwa di masa lalu?

a. Ya b. Tidak2. Pengobatan sebelumnya?

a. Berhasil b. Kurang berhasil c. Tidak berhasil3. Faktor :

Aniaya fisika. Pelaku : ..................................................................................... Usia : ............. tahunb. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun

Aniaya seksuala. Pelaku : ..................................................................................... Usia : ............. tahunb. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun

Penolakana. Pelaku : ..................................................................................... Usia : ............. tahunb. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun

Kekerasan dalam rumah tanggaa. Pelaku : ..................................................................................... Usia : ............. tahunb. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun

Tindakan kriminala. Pelaku : ..................................................................................... Usia : ............. tahunb. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun

Jelaskan no. 1, 2, 3.........................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

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

4. Adakah anggota keluarga yang mengalami gangguan jiwa?a. Ya b. TidakBila ada isi dibawah ini :Hubungan keluargaa. ..............................b. ..............................

Gejalaa. ..............................b. ..............................

Riwayat pengobatan/perawatana. ..............................b. ..............................

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

5. Pengalaman masa lalu yang tidak menyenangkan...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

IV. PENGKAJIAN FISIK1. Tanda Vital

TD : ………… mm/hg N : ………… x/menit S : ………… °C P : ………… x/menit2. Ukur tubuh

TB : ………… cm BB : ………… kg3. Keluhan Fisik

a. Ya b. TidakJelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

V. PSIKOSOSIAL1. Genogram :

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

2. Konsep diria. Gambaran diri :

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

...................................................................................................................................................b. Identitas :

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

...................................................................................................................................................c. Peran :

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

...................................................................................................................................................d. Ideal diri :

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

...................................................................................................................................................e. Harga diri :

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

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

3. Hubungan sosiala. Orang yang berarti : .......................................................................................................b. Peran serta dalam kegiatan kelompok / masyarakat :

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

...................................................................................................................................................c. Hambatan dalam berhubungan dengan orang lain :

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


4. Spirituala. Nilai dan keyakinan :

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

...................................................................................................................................................b. Kegiatan ibadah :

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


VI. STATUS MENTAL1. Penampilan

a. Tidak rapi b. Penggunaan pakaian tidak sesuai

c. Cara berpakaian tidak seperti biasanya


2. Pembicaraana. Cepatb. Kerasc. Gagap d. Inkoheren

e. Apatisf. Lambatg. Membisu

h. Tidak mampu memulai pembicaraan


3. Aktivitas motorika. Lesu b. Tegang

c. Gelisah d. Agitasi

e. TIKf. Grimasen

g. Tremor h. Kompulsif


4. Alam perasaana. Sedihb. Putus asa

c. Gembirad. Ketakutan

e. Khawatir f. Berlebihan


5. Afeka. Datar b. Tumpul c. Labil d. Tidak sesuaiJelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

6. Interaksi selama wawancaraa. Bermusuhanb. Tidak kooperatifc. Mudah tersinggungd. Kontak mata (-)e. Defensiff. Curiga


7. Persepsi

a. Pendengaranb. Penglihatan

c. Perabaand. Pengecapan

e. Penghidungan


8. Proses pikira. Sirkumtansialb. Tangensialc. Kehilangan asosiasi

d. Flight of ideae. Blocking

f. Pengulangan pembicaraan /persevarasi


9. Isi pikirana. Obsesib. Fobia

c. Hipokondriad. Depersonalisasi

e. Ide yang terkaitf. Pikiran magis

Wahama. Agamab. Somatikc. Kebesaran

d. Curigae. Nihilisticf. Sisip pikir

g. Siar pikirh. Kontrol pikir


10. Tingkat kesadarana. Bingung b. Sedasi c. StuporDisorientasia. Waktu b. Tempat c. OrangJelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

11. Memoria. Gangguan daya ingat jangka panjangb. Gangguan daya ingat saat ini

c. Gangguan daya ingat jangka pendekd. Konfabulasi

Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

12. Tingkat konsentrasi dan berhitunga. Mudah beralihb. Tidak mampu berhitung

c. Tidak mampu konsentrasi sederhana


13. Kemampuan penilaiana. Gangguan ringan b. Gangguan bermaknaJelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

14. Daya tilik diria. Mengingkari penyakit yang di derita b. Menyalahkan hal-hal di luar dirinyaJelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

VII. KEBUTUHAN PERSIAPAN PULANG1. Makan

a. Bantuan minimal b. Bantuan total2. BAB / BAK

a. Bantuan minimal b. Bantuan totalJelaskan :..................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Mandia. Bantuan minimal b. Bantuan total

4. Berpakaian / berhiasa. Bantuan minimal b. Bantuan totalJelaskan :..................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

5. Istirahat dan tidurTidur siang lama : ................ s/d .....................Tidur malam lama : ................ s/d .....................Kegiatan sebelum/sesudah tidur : ..................................................................................................................................................................................................................................................................................................................

6. Penggunaan obata. 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. TidakJelaskan :..................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

VIII. MEKANISME KOPINGAdaptif1. Bicara dengan orang lain 2. Mampu menyelesaikan masalah 3. Teknik relaksasi 4. Aktivitas konstruktif 5. Olah raga Lainnya ...........................................................

Maladaptif1. Minum alkohol2. Reaksi lambat / berlebih3. Bekerja berlebihan4. Menghindar5. Mencederai diriLainnya ............................................................

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

IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN1. 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 ...............................................................................................................

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


X. PENGETAHUAN KURANG TENTANG1. Penyakit jiwa 2. Sistem pendukung

3. Faktor presipitasi4. Penyakit fisik

5. Koping6. Obat-obatan

Lainnya .................................................................................................................................................


XI. ASPEK MEDIK1. Diagnosa medik : ........................................................................................................................

........................................................................................................................2. Terapi medik : ........................................................................................................................

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

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

XII. DAFTAR DIAGNOSA KEPERAWATAN....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

(...............................)

POHON MASALAH

Akibat

Core problem

Penyebab

ANALISA DATA

Nama klien : ..............................................Umur : ..............................................

Ruangan/kamar : ..............................................No. RM : ..............................................

No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)

INTERVENSI KEPERAWATAN

No TanggalDiagnosa

KeperawatanTujuan Kriteria evaluasi Intervensi

IMPLEMENTASI DAN EVALUASI

NoTanggal/

jamImplementasi 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 Komunikasi1. Orientasi

a. Salam terapeutik............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

b. Evaluasi validasi............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c. Kontrak1) Topik

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

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

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

.............................................................................................................................................2) Waktu

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

.............................................................................................................................................3) Tempat

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

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2. Kerja..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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3. Terminasia. 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,

(...............................)

ANALISA PROSES INTERAKSI

Inisial klien : Status interaksi P – K : Lingkungan : Deskripsi Klien : Tujuan interaksi :

Nama Mahasiswa : ................................................................................................Tanggal : ................................................................................................Waktu : ................................................................................................Tempat : ................................................................................................

Deskripsi Klien :............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

Komunikasi Verbal Komunikasi Non - VerbalAnalisa Berpusat

Pada PerawatAnalisa Berpusat

Pada KlienRasional

Komunikasi Verbal Komunikasi Non - VerbalAnalisa Berpusat

Pada PerawatAnalisa Berpusat

Pada KlienRasional

Kesan Perawat :..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Mahasiswa

(..........................................

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