FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA Ruang rawat : .......... Tanggal dirawat: ............. A. IDENTITAS KLIEN Nama : Status Perkawinan : Jenis Kelamin : Suku : Umur : No. CM : Alamat : Tanggal masuk : Agama : Tanggal Pengkajian : Pendidikan : Sumber Informasi : Pekerjaan : B. ALASAN MASUK/FAKTOR PRESIPITASI ................................................................. ................................................................. ............. ................................................................. ................................................................. ............. ................................................................. ................................................................. ............. ................................................................. ................................................................. ............. ................................................................. ................................................................. ............. ................................................................. ................................................................. ............. ................................................................. ................................................................. ............. ................................................................. ................................................................. ............. ................................................................. ................................................................. .............
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FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA
Ruang rawat : .......... Tanggal dirawat: .............
A. IDENTITAS KLIENNama : Status Perkawinan :Jenis Kelamin : Suku :Umur : No. CM :Alamat : Tanggal masuk :Agama : Tanggal Pengkajian :Pendidikan : Sumber Informasi :Pekerjaan :
B. ALASAN MASUK/FAKTOR PRESIPITASI.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
C. FAKTOR PREDISPOSISI1. Pernah mengalami gangguan jiwa di masa lalu?
Jika ada :Hubungan keluarga : ................................................................................................Gejala : .................................................................................................Riwayat pengobatan : .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Saat masuk RS : TD .....................mmHg HR : .........kali / menitS .................... oC RR : ......... kali / menitSaat pengkajian : TD .....................mmHg HR : .........kali / menit S .................... oC RR : ......... kali / menit
2. Ukur : Saat masuk RS : BB .......................... Kg TB : ......... cmSaat pengkajian : BB .......................... Kg TB : ......... cm...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Diagnosis keperawatan Risiko tinggi perubahan suhu tubuh Defisit volume cairan Risiko tinggi terhadap infeksil Ketidakseimbangan nutrisi: kurang dari
kebutuhan tubuh Ketidakseimbangan nutrisi: kurang dari
kebutuhan tubuh
Perubahannutrisi potensial lebih dari kebutuhan tubuh
Kerusakan integritas jaringan Perubahan membran mukosa oral Kerusakan integritas kulit Perubahan eliminasi feses Perubahan pola eliminasi urin ……………………………………………..
d. Ideal Diri : ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
e. Harga Diri : .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. Hubungan sosiala. Orang yang berarti : ................................
/ masyarakat ……………………………………................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c. Hambatan dalam berhubungan dengan orang lain …………………………………………...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Spirituala. Nilai dan keyakinan ................................................
.............................................................................................................................................b. Kegiatan ibadah ..................................................................................................................
Bagaimana penampilan klien dalam hal berpakaian, mandi, toileting, dan pemakaian sarana /prasarana atau instrumentasi dalam mendukung penampilan, apakah klien:
Tidak sesuai...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Risiko cidera Kerusakan komunikasi verbal Kerusakan interaksi sosial ……………………………………………..
Diagnosis keperawatan Kerusakan komunikasi verbal Kerusakan interaksi sosial Isolasi sosial Risiko bunuh diri Risiko tinggi membahayakan diri Perilaku kekerasan Risiko perilaku kekerasan : (pada diri, orang lain,
Lama tidur siang : ........ JamApa yang menolong tidur ? ........................................................................Tidur malam jam : ................................, berapa jam : ...............................Apakah ada gangguan tidur ?
Sulit untuk tidur
Bangun terlalu pagiSomnambulismeTerbangun saat tidurGelisah saat tidurBerbicara saat tidur
Diagnosis keperawatan Penatalaksanaan regimen terapeutik individu inefektif Penatalaksanaan Regimen terapeutik keluarga inefektif Ketidakpatuhan Konflik pengambilan keputusan ………………………………………
Diagnosis keperawatan Perilaku mencari bantuan tentang …………………………………. ………………………………………
....................................................................................................................................................5. Aktivitas Di Dalam Rumah
Ya TidakMempersiapkan makananMenjaga kerapian rumahMencuci pakaian
...................................................................................................................................................6. Aktivitas Di Luar Rumah
Adaptif: Maladaptif:Bicara dengan orang lain Minum alkoholMampu menyelesaikan masalah Reaksi lambat/berlebihTeknik relokasi Berkerja berlebihanAktivitas konstruktif Menghindar Olah raga Menciderai diri
Masalah dengan dukungan kelompok/keluarga, uraikan .........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan lingkungan, uraikan .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan pendidikan, uraikan ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan pekerjaan, uraikan ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan perumahan, uraikan ...........................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan ekonomi, uraikan ...............................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan pelayanan kesehatan, uraikan .........................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan lainnya, uraikan .......................................................................................................................................................................................................................................................
Diagnosis keperawatan
Koping individu inefektif ………………………………………
Diagnosis keperawatan
Perubahan pemeliharaan kesehatan Perilaku mencari bantuan kesehatan tentang …………… Ketidakberdayaan Konflik peran orang tua Sindroma stres Relokasi Penatalaksanaan regimen terapeutik individu inefektif Penatalaksanaan Regimen terapeutik keluarga inefektif
J. ASPEK MEDISDiagnosis medis : ...............................................................................................Terapi medis : ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
K. DAFTAR DIAGNOSIS KEPERAWATAN1. .................................................................................................................................2. .................................................................................................................................3. .................................................................................................................................4. .................................................................................................................................5. .................................................................................................................................6. .................................................................................................................................7. .................................................................................................................................8. .................................................................................................................................9. .................................................................................................................................10. .................................................................................................................................11. .................................................................................................................................12. .................................................................................................................................13. .................................................................................................................................14. .................................................................................................................................15. .................................................................................................................................