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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2. MASALAH  KEPERAWATAN

ANALISA DATA

No	Data	Masalah keperawatan

C.    DAFTAR MASALAH

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D.        POHON MASALAH

E.     DIAGNOSA KEPERAWATAN

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