Pengkajian-keperawatan-kesehatan-jiwa(1).docx

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

PENGKAJIAN KEPERAWATAN KESEHATAN JIWA FAKULTAS KEPERAWATAN UNIVERSITAS ANDALAS

A. Pengkajian Ruang Rawat

: ...........................................................................................

Nama Perawat

: ...........................................................................................

I. Identitas Klien Inisial Klien

: .....................................................................................

Umur

: ....................................................................................

Informan

: .....................................................................................

Tanggal pengkajian: ..................................................................................... No. MR

: ....................................................................................

Tanggal masuk

: ....................................................................................

Alamat

: ....................................................................................

II. Riwayat Kesehatan ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... .......................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

III. Faktor Predisposisi ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... Masalah Keperawatan : ................................................................................

IV. Pemeriksaan Fisik a. Tanda Vital

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................................................................................................................. b. Ukuran

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c. Keluhan Fisik : ....................................................................................... ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ................................................................................

V. Psikososial a. Genogram

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

Keterangan : = perempuan = laki-laki = meninggal = klien _ _ _ _ _ = tinggal serumah

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b. Konsep Diri 1. Citra Tubuh ........................................................................................................... ........................................................................................................... ........................................................................................................... ........................................................................................................... ...........................................................................................................

2. Identitas Diri ........................................................................................................... ........................................................................................................... ........................................................................................................... ...........................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

3. Peran ........................................................................................................... ........................................................................................................... ........................................................................................................... ........................................................................................................... ...........................................................................................................

4. Ideal Diri ........................................................................................................... ........................................................................................................... ........................................................................................................... ........................................................................................................... ...........................................................................................................

5. Harga Diri ........................................................................................................... ........................................................................................................... ........................................................................................................... ........................................................................................................... ........................................................................................................... Masalah Keperawatan : ....................................................................

c. Hubungan Sosial ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

d. Spritual ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

VI.

Status Mental a. Penampilan ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

b. Pembicaraan ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

c. Aktifitas Motorik ................................................................................................................. ................................................................................................................. .................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

d. Alam Perasaan ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

e. Afek ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

f. Interaksi Selama Wawancara ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

g. Persepsi ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

h. Proses Berfikir ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

i. Isi Pikir ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

j. Tingkat Kesadaran ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

k. Memori ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

l. Tingkat Konsentrasi dan Berhitung ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

m. Kemampuan Penilaian ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

n. Daya Tilik Diri ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

VII.

Kebutuhan Persiapan Pulang

a. Makan ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

b. BAB/ BAK ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

c. Mandi ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

d. Pakaian ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

e. Istirahat ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

f. Penggunaan Obat ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

g. Pemeliharaan Kesehatan ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

h. Aktifitas di Rumah ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

i. Aktifitas di Luar Rumah ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

VIII. Mekanisme Koping a. Mekanisme Adaptif ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

b. Mekanisme Maladaptif ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

IX. Masalah Psikososial dan Lingkungan a. Masalah Behubungan dengan Lingkungan ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

b. Masalah dengan Pekerjaan ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

c. Masalah dengan Perumahan ................................................................................................................. .................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

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

d. Masalah Ekonomi ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

e. Masalah dengan Pelayanan Kesehatan ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. Masalah Keperawatan : ..........................................................................

X. Pengetahuan ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... Masalah Keperawatan : ................................................................................

XI. Aspek Medis Diagnosa Medis : ......................................................................................... Terapi Medis :

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Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

B. MASALAH KEPERAWATAN

ANALISA DATA

No.

Data

Masalah Keperawatan

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

C. DAFTAR MASALAH ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. .............................................................................................................................

D. POHON MASALAH

E. DIAGNOSA KEPERAWATAN ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... ...........................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA KELUARGA/ MASYARAKAT

Nama

: ...................................................

Umur

: ...................................................

Suku/ Ras

: ...................................................

Status Pernikahan

: ...................................................

Pendidikan

: ...................................................

Pekerjaan

: ...................................................

Alamat

: ...................................................

Jumlah Anak

: ...................................................

Jumlah Anak yang Ada di Rumah

: ...................................................

Jumlah Anak yang Tidak Ada di Rumah

: ...................................................

Jumlah Anak yang Sudah Menikah

: ...................................................

Jumlah Anggota Keluarga yang Ada di Rumah : ...................................................

A. PENGKAJIAN BIOLOGIS 1. Perumahan: permanen/ semi permanen ....................................................................................................................... 2. Kepemilikan Rumah: milik sendiri/ sewa/ kontrakan/ lain-lain ....................................................................................................................... 3. Kebersihan Rumah: bersih/ cukupbersih/ kurang bersih ....................................................................................................................... .......................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

4. Jarak rumah dengan rumah tetangga terdekat ....................................................................................................................... 5. Kebiasaan perilaku keluarga yang menguntungkan ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... 6. Kebiasaan perilaku keluarga yang merugikan ....................................................................................................................... ....................................................................................................................... 7. Pelayanan kesehatan yang tersedia ....................................................................................................................... ....................................................................................................................... 8. Mutu pelayanan kesehatan yang tersedia ....................................................................................................................... ....................................................................................................................... 9. Jarak pelayanan kesehatan yang tersedia dekat rumah ....................................................................................................................... ....................................................................................................................... 10. Jenis obat yang dikonsumsi keluarga ....................................................................................................................... ....................................................................................................................... 11. Karakteristik lingkungan tempat tinggal keluarga ....................................................................................................................... .......................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

12. Tradisi yang sering dilakukan kelurga ....................................................................................................................... ....................................................................................................................... 13. Sikap keluarga terhadap tradisi tersebut ....................................................................................................................... ....................................................................................................................... 14. Apakah keluarga mau menerima perubahan ....................................................................................................................... ....................................................................................................................... 15. Siapa yang diuntungkan dalam perubahan tersebut ....................................................................................................................... .......................................................................................................................

B. PENGKAJIAN PSIKOSOSIAL 1. Siapa yang mengambil keputusan dalam keluarga ....................................................................................................................... ....................................................................................................................... 2. Anggota keluarga yang sakit dan penyakitnya ....................................................................................................................... ....................................................................................................................... 3. Anggota kelurga (anak) usia < 5 tahun : ....................................................................................................................... .......................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

4. Anggota keluarga (usila) usia > 65 tahun ....................................................................................................................... ....................................................................................................................... 5. Kasus Perceraian dalam keluarga inti ....................................................................................................................... ....................................................................................................................... 6. Anggota keluarga yang abnormal ....................................................................................................................... ....................................................................................................................... 7. Anggota keluarga yang lari dari rumah ....................................................................................................................... ....................................................................................................................... 8. Kejadian yang dapat menimbulkan masalah

....................................................................................................................... ....................................................................................................................... 9. Masalah yang terjadi sampai 2 tahun belakang ini ....................................................................................................................... ....................................................................................................................... 10. Masalah yang mungkin terjadi 2 tahun ke depan ....................................................................................................................... ....................................................................................................................... 11. Hubungan antar anggota keluarga ....................................................................................................................... .......................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

12. Kemampuan dan jenis koping keluarga ....................................................................................................................... ....................................................................................................................... 13. Pola hubungan dan interaksi dalam keluarga ....................................................................................................................... ....................................................................................................................... 14. Keterlibatan kelurga dalam kegiatan masyarakat ....................................................................................................................... ....................................................................................................................... 15. Apakah ada orang lain yang sering membantu memecahkan masalah dalam kelurga ....................................................................................................................... ....................................................................................................................... 16. Pemahaman kelurga tentang sehat sakit ....................................................................................................................... ....................................................................................................................... 17. Apakah anggota keluarga pernah di rawat/ berobat karena gangguan jiwa ....................................................................................................................... ....................................................................................................................... 18. Penerimaan lingkungan terhadap anggota kelurga yang pernah dirawat / berobat karena gangguan jiwa ....................................................................................................................... .......................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

19. Bentuk penerimaan atau penolakan yang tampak ....................................................................................................................... ....................................................................................................................... 20. Pengalaman/ kejadian krisis yang merupakan stressor bagi keluarga ....................................................................................................................... ....................................................................................................................... 21. Harapan keluarga terhadap masa yang akan datang ....................................................................................................................... .......................................................................................................................

Lhona, S. Kep 1541312024

Praktek Profesi Keperawatan Jiwa FakultasKeperawatan UNAND

C. MASALAH KEPERAWATAN ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. .............................................................................................................................

D. DIAGNOSA KEPERAWATAN ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. .............................................................................................................................

Lhona, S. Kep 1541312024