Praktek Profesi Ners Keperawatan 2017/2018

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

FORMAT PENGKAJIAN KEPERAWATAN JIWA

PRAKTEK PROFESI NERS STIKES FORT DE KOCK
Di RSJ PROVINSI JAWA BARAT

Ruang Rawat :
Tanggal Mrs :

I. IDENTITAS KLIEN
Inisial :
Umur :
Informan :
Alamat Lengkap :
Tanggal Pengkajian :
No MR :

II. ALASAN MASUK

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III. FAKTOR PREDISPOSISI

1. Gangguan Jiwa masa lalu
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2. Pengobatan Sebelumnya
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STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

3. Trauma
 Aniaya Fisik
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Masalah Keperawatan :

 Aniaya Seksual
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Masalah Keperawatan :

 Penolakan
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Masalah Keperawatan :

 Kekerasan dalam Keluarga

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Masalah Keperawatan :

 Tindakan Kriminal
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Masalah Keperawatan:

4. Anggota Keluarga yg Mengalami Gangguan Jiwa

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Masalah Keperawatan :

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

5. Pengalaman masa lalu yang tidak menyenangkan

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Masalah Keperawatan :

IV. Pemeriksaan Fisik

1. Tanda Vital : TD : N:
S: P:
2. Ukuran : TB: BB:
3. Keluhan Fisik
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Masalah Keperawatan :

V. PSIKOSOSIAL
1. Genogram

: Laki-laki meninggal : Laki-laki

: Perempuan meninggal ----- : Tinggal satu rumah

: Perempuan : Klien

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

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Masalah Keperawatan :

2. Konsep Diri
a. Citra Tubuh
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b. Identitas Diri
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c. Peran Diri
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d. Ideal Diri
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e. Harga Diri
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Masalah keperawatan :

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

3. Hubungan Sosial
a. Orang Terdekat
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b. Peran serta dalam kegiatan kelompok/masyarakat

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c. Hambatan dalam berhubungan dengan orang lain

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Masalah keperawatan :

4. Spiritual
a. Nilai dan keyakinan
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b. Kegiatan ibadah
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Masalah keperawatan :

VI. STATUS MENTAL

1. Penampilan
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Masalah Keperawatan :

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

2. Pembicaraan
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Masalah Keperawatan :

3. Aktifitas Motorik
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Masalah Keperawatan :

4. Alam Perasaan
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Masalah Keperawatan :

5. Afek
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Masalah Keperawatan :

6. Interaksi Selama Wawancara

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Masalah Keperawatan :

7. Persepsi
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Masalah Keperawatan :

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

8. Proses Fikir
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Masalah Keperawatan :

9. Isi Pikir
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Masalah Keperawatan :

10. Tingkat Kesadaran

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Masalah Keperawatan :

11. Memori
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Masalah Keperawatan :

12. Tingkat Konsentrasi dan Menghitung

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Masalah Keperawatan :

13. Kemampuan Penilaian

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Masalah Keperawatan :

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

14. Daya Tilik Diri

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Masalah Keperawatan :

VII. KEBUTUHAN PERSIAPAN PULANG

1. Makan
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Masalah Keperawatan :

2. BAB/BAK
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Masalah Keperawatan :

3. Mandi
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Masalah Keperawatan :

4. Berpakaian / Berhias
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Masalah Keperawatan :

5. Istirahat dan Tidur

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Masalah Keperawatan :

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

6. Penggunaan Obat
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Masalah Keperawatan :

7. Pemeliharaan Kesehatan
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Masalah Keperawatan :

8. Kegiatan Didalam Rumah

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Masalah Keperawatan :

9. Kegiatan Diluar Rumah

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Masalah Keperawatan :

VIII. MEKANISME KOPING

1. Adaptif
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2. Maladaptif
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Masalah Keperawatan :

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

1. Masalah dengan Dukungan Kelompok
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2. Masalah Berhubungan dengan Lingkungan

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3. Masalah dengan Pendidikan

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4. Masalah dengan Pekerjaan

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5. Masalah Ekonomi
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6. Masalah dengan Pelayanan Kesehatan

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X. KURANG PENGETAHUAN
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Masalah keperawatan :

XI. ASPEK MEDIK

1. Diagnosa medik
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STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

2. Terapi medik
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STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

ANALISA DATA

No Data Masalah Keperawatan

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

XII. DAFTAR MASALAH KEPERAWATAN

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XIII. POHON MASALAH

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STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018

XIV DAFTAR DIAGNOSA MASALAH

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STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018 Ammi Mardhatillah ,S.Kep
1614901182

RENCANA TINDAKAN KEPERAWATAN

Inisial Klien : Ruangan : No MR :
Rencana Tindakan Keperawatan
Diagnosa
Tujuan Kriteria Hasil Intervensi

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018 Ammi Mardhatillah ,S.Kep
1614901182

IMPLEMENTASI DAN EVALUASI

Hari / Paraf
No Implementasi Evaluasi
Tanggal Mahasiswa

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018 Ammi Mardhatillah ,S.Kep
1614901182

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018 Ammi Mardhatillah ,S.Kep
1614901182

STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Hari / Tanggal :.......................................................................................................

Nama Pasien :.......................................................................................................
No MR :.......................................................................................................
Dx / SP Ke / Pertemuan Ke :.......................................................................................................
Nama Perawat Pelaksana :.......................................................................................................

A. PROSES KEPERAWATAN
1. Kondisi Klien
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2. Diagnosa keperawatan
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STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018 Ammi Mardhatillah ,S.Kep
1614901182

3. Tujuan Khusus
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4. Tindakan Keperawatan
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B. Strategi Pelaksanaan
1. Fase Orientasi
a. Salam Terapeutik
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b. Evaluasi/Validasi
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_________________Waktu

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018 Ammi Mardhatillah ,S.Kep
1614901182

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2. Fase Kerja
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3. Fase Terminasi
a. Evaluasi Respon Klien Terhadap Tindakan Keperawatan
Evaluasi Subjektif
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Evaluasi Objektif
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b. Rencana Tindak Lanjut

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018 Ammi Mardhatillah ,S.Kep
1614901182

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c. Kontrak yang akan datang

Topik
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Tempat
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STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018 Ammi Mardhatillah ,S.Kep
1614901182

ANALISA PROSES INTERAKSI (API)

Inisial Klien : Ruangan : Tujuan :

Hari/tanggal : Lingkungan :
Interaksi : Deskripsi :

Analisa Berpusat Pada Analisa Berpusat Pada

Komunikasi Verbal Komunikasi Non Verbal Rasional
Perawat Klien

STIKes Fort De Kock Bukittinggi

Praktek Profesi Ners Keperawatan 2017/2018 Ammi Mardhatillah ,S.Kep
1614901182

Komunikasi Verbal Komunikasi Non Verbal Analisa Berpusat Pada Analisa Berpusat Pada Rasional
Perawat Klien

STIKes Fort De Kock Bukittinggi