Minggu, 07 April 2013

FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA DI MENUR - SURABAYA


STIKES PEMKAB JOMBANG
 
Ruang rawat         :                                     Tanggal Dirawat   :

I.         IDENTITAS KLIEN
Inisial         :                                (L / P)   Tanggal Pengkajian   :                           
Umur         :                                             RM No.                      :                           
Informan    :                                                                                                           
II.       ALASAN MASUK
                                                                                                                     
                                                                                                                     
III.     FAKTOR PREDISPOSISI
1.   Pernah mengalami gangguan jiwa di masa lalu ?       Ya           Tidak
2.   Pengobatan sebelumnya         Berhasil        Kurang berhasil        Tdk berhasil
3.                                             Pelaku/Usia             Korban/Usia   Saksi/Usia
Aniaya fisik
Aniaya seksual
Penolakan
Kekerasan dalam keluarga
Tindakan kriminal
Jelaskan No. 1, 2, 3     :                                                                           
                                                                                                                
Masalah Keperawatan :                                                                           
                                                                                                                





4.   Adakah anggota keluarga yang mengalami gangguan jiwa ?                Ya        Tidak
 Hubungan Keluarga            Gejala                                       Riwayat Pengobatan/
              Perawatan
                                                                                                                          
                                                                                                                          
Masalah Keperawatan :                                                                                    
5.   Pengalaman masa lalu yang tidak menyenangkan
                                                                                                                         
                                                                                                                         
Masalah Keperawatan :                                                                                     
IV.     FISIK
1.   Tanda vital :       TD :                       N :                S :                        P :              
2.   Ukur :                TB :                       BB :                            Turun             Naik
3.   Keluhan Fisik :                     Ya                         Tidak
Jelaskan :                                                                                                              
Masalah Keperawatan :                                                                                         
V.       PSIKOSOSIAL
1.   Genogram
Jelaskan :                                                                                                         
Masalah Keperawatan :                                                                                    
2.   Konsep diri :
a.     Citra tubuh :                                                                                                                                                                                                      
b.     Identitas       :                                                                                                                                                                                          
c.     Peran            :                                                                                                                                                                                          
d.     Ideal diri       :                                                                                                                                                                                          
e.     Harga diri     :                                                                                                                                                                                          
Masalah Keperawatan :                                                                                    
3.   Hubungan Sosial :
a.     Orang terdekat :                                                                                                                                                                                 
b.     Peran serta dalam kegiatan kelompok / masyarakat :
                                                                                                                    
c.     Hambatan dalam berhubungan dengan orang lain :
                                                                                                                    
Masalah Keperawatan :                                                                                    
4.   Spiritual :
a.    Nilai dan keyakinan :
                                                                                                                     
                                                                                                                     
b.   Kegiatan ibadah :
                                                                                                                     
                                                                                                                     
Masalah Keperawatan :                                                                                    

VI.     STATUS MENTAL
1.   Penampilan       
Tidak rapi             Penggunaan pakaian               Cara berpakaian tidak
                             tidak sesuai                                       seperti biasanya
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    
2.   Pembicaraan
          Cepat             Keras             Gagap                    Inkoheren
          Apatis             Lambat           Membisu                Tidak mampu memulai
                                                                                      Pembicaraan
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    

3.   Aktivitas Motorik
          Lesu               Tegang              Gelisah               Agitasi
          Tik                 Grimasen          Tremor                Kompulsif
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    
4.   Alam Perasaan
          Sedih          Ketakutan         Putus asa          Khawatir        Gembira
                                                                                                       berlebihan
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    
5.   Afek
                      Datar              Tumpul             Labil                   Tidak sesuai
6.   Interaksi selama wawancara
         Bermusuhan                      Tidak kooperatif           Mudah tersinggung
         Kontak mata kurang           Defensif                        Curia
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    
7.   Persepsi
Halusinasi
       Pendengaran                 Penglihatan                   Perabaan
       Pengecapan                             Penghidu
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    
8.   Proses Pikir
          Sirkumstansial           Tangensial            Kehilangan asosiasi
          Flight of ideas             Blocking               Pengulangan pembicaraan/
                                                                          Preservasi
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    


9.   Isi Pikir
            Obsesi                         Fobia                              Hipokondria
            Depersonalisasi          Ide yang terkait             Pikiran magis
Waham
            Agama               Somatik              Kebesaran              Curiga
            Nihilistik           Sisip pikir           Siar pikir                Kontrol pikir
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    
10.    Tingkat Kesadaran
              Bingung              Sedasi            Stupor
Disorientasi :
               Waktu                 Tempat           Orang
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    
11.    Memori
Gangguan daya ingat jangka panjang        Gangguan daya ingat jangka pendek








 

Gangguan daya ingat saat ini                     Konfabulasi
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    
12.    Tingkat Konsentrasi dan Berhitung
Mudah beralih           Tidak mampu                 Tidak mampu berhitung berkonsentrasi               sederhatan
13.    Kemampuan Penilaian
Gangguan ringan                    Gangguan bermakna
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    

14.    Daya tilik diri
Menginginkan penyakit yang diderita            Menyalahkan hal-hal
                                                                        Diluar dirinya.
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    

VII.   KEBUTUHAN PERSIAPAN PULANG
1.   Makan
            Bantuan Minimal                         Bantuan total
2.   BAB / BAK
            Bantuan Minimal                         Bantuan total
3.   Mandi
            Bantuan Minimal                         Bantuan total
4.   Berpakaian / berhias
            Bantuan Minimal                         Bantuan total
5.   Istirahat dan tidur
            Tidur siang lama :                                   s/d                               
            Tidur malam lama :                                 s/d                               
            Aktivitas sebelum / sesudah tidur :                            s/d                    
6.   Penggunaan obat
            Bantuan Minimal                         Bantuan total
7.   Pemeliharaan kesehatan
Ya               Tidak
Perawatan Lanjutan
Sistem Pendukung
8.   Aktivitas di dalam rumah
Ya               Tidak
Mempersiapkan makanan
Menjaga kerapihan rumah
Mencuci pakaian
Pengaturan keuangan
9.   Aktivitas di luar rumah
Ya               Tidak
Belanja
Transportasi
Lain – lain
Jelaskan :                                                                                                        
Masalah Keperawatan :                                                                                    

VIII.   MEKANISME KOPING
Adaptif                                                        Maladaptif
          Bicara dengan orang lain                                       Minum alkohol
          Mampu menyelesaikan masalah                  Reaksi lambat / berlebih
          Teknik relokasi                                            Bekerja berlebihan
          Aktivitas konstruktif                                     Menghindar
          Olah raga                                                     Mencederai diri
          Lainnya                                                        Lainnya
Masalah Keperawatan :                                                                                         

IX.       MASALAH PSIKOSOSIAL DAN LINGKUNGAN
            Masalah dengan dukungan kelompok, uraikan
                                                                                                                              
            Masalah berhubungan dengan lingkungan, uraikan
                                                                                                                              
            Masalah dengan pendidikan, uraikan
                                                                                                                              
            Masalah dengan pekerjaan, uraikan
                                                                                                                              
            Masalah dengan perumahan, uraikan
                                                                                                                              
            Masalah dengan ekonomi, uraikan
                                                                                                                              
            Masalah dengan pelayanan kesehatan, uraikan
                                                                                                                              
            Masalah lainnya, uraikan
                                                                                                                  
Masalah keperawatan :                                                                                      

X.         KURANG PENGETAHUAN TENTANG
            Penyakit jiwa                                    Sistem pendukung
            Faktor presipitasi                              Penyakit fisik
            Koping                                              Obat-obatan
            Lainnya :                                                                                                   
Masalah Keperawatan :                                                                                         

XI.       ASPEK MEDIK
Diagnosa medik    :                                                                                               
                                                                                                                              
Terapi medik         :                                                                                               
                                                                                                                              
                                                                                                                              

XII.     DAFTAR MASALAH KEPERAWATAN
                                                                                                                              
                                                                                                                              
                                                                                                                              
                                                                                                                              
                                                                                                                              


XIII.   DIAGNOSA KEPERAWATAN
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           

                                                         
Mahasiswa,



                                                         

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