PENGKAJIAN KEPERAWATAN KESEHATAN JIWA



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
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III.             Faktor Predisposisi
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Masalah Keperawatan :

IV.             Pemeriksaan Fisik
a.       Tanda vital            : ......................................................................................
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b.      Ukuran                  : ......................................................................................  
c.       Keluhan fisik         : ......................................................................................
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Masalah Keperawatan :

V.                Psikososial
a.          Genogram











            Keterangan      :
                                    =  Perempuan
                                    =  Laki-laki
                                    =  Meninggal
=  Klien
                                    =  Orang terdekat dengan klien
                                    =  Tinggal serumah
           
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     Masalah Keperawatan :


b.          Konsep diri
1.          Citra Tubuh
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2.     Identitas diri
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3.          Peran
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4.          Ideal diri
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5.          Harga diri
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Masalah Keperawatan :


c.       Hubungan sosial
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        Masalah Keperawatan :
d.          Spritual
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                    Masalah Keperawatan :

VI.             Status mental
a.           Penampilan
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Masalah Keperawatan :

b.          Pembicaraan
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Masalah Keperawatan :

c.           Aktivitas motorik
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Masalah Keperawatan :

d.          Alam perasaan
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Masalah Keperawatan :

e.           Afek
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Masalah Keperawatan :

f.           Interaksi selama wawancara
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Masalah Keperawatan :


g.          Persepsi
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Masalah Keperawatan :

h.          Proses pikir
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Masalah Keperawatan :

i.            Isi pikir
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Masalah Keperawatan :

j.            Tingkat kesadaran
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Masalah Keperawatan :

k.          Memori
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Masalah Keperawatan :

l.            Tingkat konsentrasi dan berhitung
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Masalah Keperawatan :

m.        Kemampuan penilaian
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Masalah Keperawatan :

n.          Daya tilik diri
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Masalah Keperawatan :

VII.          Kebutuhan Persiapan Pulang
a.           Makan
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b.          BAB/BAK
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c.           Mandi
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d.          Pakaian
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e.           Istirahat
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f.           Penggunaan obat
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g.          Pemeliharaan kesehatan
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h.          Aktivitas di Dalam Rumah
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i.            Aktivitas di Luar Rumah
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Masalah Keperawatan :

VIII.       Mekanisme Koping
a.           Mekanisme adaptif
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b.          Mekanisme mal adaptif
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            Masalah Keperawatan     :

IX.             Masalah Psikososial dan Lingkungan
a.           Masalah berhubungan dengan lingkungan
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b.          Masalah dengan pekerjaan
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c.           Masalah dengan perumahan
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d.          Masalah ekonomi
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e.           Masalah dengan pelayanan kesehatan
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            Masalah Keperawatan     :

X.                Pengetahuan
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            Masalah Keperawatan     :


XI.             Aspek Medis
Diagnosa Medis    : ...........................................................................................
Therapi Medis       : ............................................................................................
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  1. MASALAH  KEPERAWATAN

ANALISA DATA
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Data
Masalah keperawatan











































































































































































C.    DAFTAR MASALAH
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D.        POHON MASALAH












E.     DIAGNOSA KEPERAWATAN
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