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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 :
...................................................................................................................................................
...................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Spirituala. Nilai dan keyakinan :
...................................................................................................................................................
...................................................................................................................................................b. Kegiatan ibadah :
...................................................................................................................................................
...................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VI. STATUS MENTAL1. Penampilan
a. Tidak rapi b. Penggunaan pakaian tidak sesuai
c. Cara berpakaian tidak seperti biasanya
Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. Pembicaraana. Cepatb. Kerasc. Gagap d. Inkoheren
e. Apatisf. Lambatg. Membisu
h. Tidak mampu memulai pembicaraan
Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Aktivitas motorika. Lesu b. Tegang
c. Gelisah d. Agitasi
e. TIKf. Grimasen
g. Tremor h. Kompulsif
Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Alam perasaana. Sedihb. Putus asa
c. Gembirad. Ketakutan
e. Khawatir f. Berlebihan
Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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
Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
a. Pendengaranb. Penglihatan
c. Perabaand. Pengecapan
e. Penghidungan
Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
8. Proses pikira. Sirkumtansialb. Tangensialc. Kehilangan asosiasi
d. Flight of ideae. Blocking
f. Pengulangan pembicaraan /persevarasi
Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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
Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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
Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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 ...............................................................................................................
.........................................................................................................................................................
Masalah keperawatan : .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
X. PENGETAHUAN KURANG TENTANG1. Penyakit jiwa 2. Sistem pendukung
3. Faktor presipitasi4. Penyakit fisik
5. Koping6. Obat-obatan
Lainnya .................................................................................................................................................
Masalah keperawatan : .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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)
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
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
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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