FORMAT LAPORAN

PRAKTIK KLINIK KEPERAWATAN JIWA

Nama Praktikan
Tempat Praktik
Waktu Praktik
Metode
Sumber Data

: Siska Kurnia Dewi

: Ruang Perkasa RSJD Dr. RM Soedjarwadi, Klaten, Jateng
: 2 Desember 2013 21 Desember 2013
: Studi Dokumentasi, Wawancara
: Pasien, Perawat, Rekam Medik

A. PENGKAJIAN
1. Identitas
a. Klien
Nama
Umur
Jenis kelamin
Agama
Alamat
Pendidikan
Pekerjaan
Suku
Status Perkawinan
No CM
Diagnosa Medis
Tanggal Masuk
Tanggal Pengkajian

: Tn. H
: 26 Tahun
: Laki-laki
: Islam
: Jombor, Jombor, Ceper, Klaten
: SMP
: Tidak Bekerja
: Jawa
: Belum Menikah
: 01.13.28
: Skizofrenia Residual
: 21-11-2013
: 03 Desember 2013

b. Penanggung Jawab
Nama
Jenis Kelamin
Pekerjaan
Agama
Hub dg Klien
Alamat

: Tn. Warsidi
: Laki-laki
: Buruh
: Islam
: Ayah
: Jombor, Jombor, Ceper, Klaten

2. Keluhan utama saat dikaji

Pasien mengatakan mendengar sesuatu yang mengancam seperti menyuruh dia
untuk pergi dari rumah dan membakar rumah. Respon pasien saat diwawancara

3.

Alasan Masuk
Sejak 1 minggu yang lalu pasien mulai sering tampak sulit tidur, mudah marah
jika keinginan tidak terpenuhi,terkadang pasien berbicara sendiri dan tertawa-

tertawa,pasien sering mukul orang tuanya, mondar-mandir dan tidak pernah mau
diajak untuk control ke RSJ.

4. Faktor Predisposisi
Pasien mengatakan waktu dirumah hanya mengurung diri dikamar, karena pasien
mengattakan sering mendengar bisikan-bisikan yang mengancam.

Masalah Keperawatan :

5. Diagnosa Medis pada saat MRS

Diagnosa Medis: Skizofrenia residual
Axis 1
:
Axis 2
:
Axis 3
:
Axis 4
:
Axis 5
:
6. Pemeriksaan Fisik
a. Keadaan Umum
Pasien tampak bingung,
b. Tingkat Kesadaran
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c. Tanda Vital
Tensi Darah : .......................
Nadi
: .......................
Suhu
: .......................
Pernapasan : .......................
d. Ukur
Berat Badan : .......................
Tinggi Badan : .......................
Masalah Keperawatan :
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7. Pengkajian Psikososial

a. Genogram (minimal 3 generasi)

b. Konsep Diri
1) Citra Tubuh
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2) Identitas Diri
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3) Peran Diri
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4) Ideal Diri
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5) Harga Diri
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Masalah Keperawatan :
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8. Hubungan dengan Keluarga dan Masyarakat

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Masalah Keperawatan
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9. Spiritual/Keyakinan
a. Nilai dan Keyakinan
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b. Kegiatan Ibadah
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Masalah Keperawatan
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10. Status Mental

a. Penampilan
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Masalah Keperawatan
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b. Pembicaraan
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Masalah Keperawatan
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c. Aktivitas Motorik
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Masalah Keperawatan
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d. Alam Perasaan
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Masalah Keperawatan
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e. Afek
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Masalah Keperawatan
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f. Interaksi Selama Wawancara

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Masalah Keperawatan
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g. Persepsi
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Masalah Keperawatan
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h. Proses Pikir
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Masalah Keperawatan
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i. Isi Pikir
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Masalah Keperawatan
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j. Tingkat kesadaran
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Masalah Keperawatan
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k. Memori
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Masalah Keperawatan
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l. Tingkat konsentrasi dan berhitung
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Masalah Keperawatan
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m. Kemampuan Penilaian
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Masalah Keperawatan
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n. Daya Tilik Diri

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Masalah Keperawatan
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11. Kebutuhan Persiapan Pulang
No
1.

2.

3.

4.

5.

Aspek yang Dinilai

Makan
a.Kemampuan menyiapkan makanan
b. Kemampuan membersihkan alat makan
c.Kemampuan menempatkan alat makan dan
minum ditempatnya
BAB/BAK
a. Kemampuan mengontrol BAK/BAB di WC
b. Kemampuan membersihkan WC
c. Kemampuan membersihan diri
d. Kemampuan memakai pakaian/celana
Mandi
a. Kemampuan dalam mandi
b. Kemampuan dalam menggosok gigi
c. Kemampuan dalam keramas
d. Kemampuan dalam potong kuku dan rambut
Berpakaian/berdandan
a. Kemampuan memilih pakaian
b. Kemampuan memakai pakaian
c. Kemampuan mengatur frekuensi ganti
pakaian
d. Kemampuan mencukur jenggot (laki-laki)
e. Kemampuan berhias (perempuan)
f.Kemampuan menyisir rambut
Istirahat dan Tidur
a. Kemampuan untuk mengatur waktu tidur
b. Kemampuan merapikan sprei dan selimut
c. Kemampuan untuk tidur dengan bantuan
obat

Tingkat
Kemampuan
0
1
2

6.
7.

8.

9.

10.

Penggunaan Obat
Kemampuan pengaturan penggunaan obat
Pemeliharaan Kesehatan
a. Perawatan Lanjutan (Puskesmas, RS, RSJ,
Perawat, dokter)
b. Perawatan Pendukung (keluarga, pengawas
minum obat)
Kegiatan di Dalam Rumah
a. Kemampuan mempersiapkan makanan
b. Kemampuan menjaga kerapihan rumah
c.kemampuan mencuci pakaian
d. Kemampuan pengaturan keuangan
Kegiatan Di Luar Rumah
a. Kemampuan berbelanja
b. Kemampuan transportasi
Lain-lain (jelaskan):
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Ket :
0 : Bantuan Total
1 : Bantuan Minimal
2 : Mandiri

12. Mekanisme Koping

a. Jenis Mekanisme Koping
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b. Sumber Mekanisme Koping
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Masalah Keperawatan

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Pemeriksaan Penunjang
a. Laboratorium
Tanggal
Selasa,
3 Desember
2013

Test

Hasil

Nilai Normal

Keterangan

HBsAg

Negatif

WBC

12,44 x 103/uL

4,50 11,00

Tinggi

RBC

4,20 x 106/uL

4,50 5,50

Rendah

Neut %

88,1 %

55,0 80,0

Tinggi

Neut #

10,96 x 103/uL

2,0 7,0

Tinggi

Lym %

8,7 %

22,0 44,0

Rendah

b. Data Diagnostik : Foto radiologi/EEG/MRI/CT-Scan dll

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Terapi Medis
Tanggal
Selasa,
3 Desember
2013

Nama Obat
1. Inj. Lodomer

Dosis/Rute
1 x 5mg / IM

2. Inj. Delladryl
3. Ampodipin

1 x 10mg / Oral

4. RPD (Risperidone)

2 x 2mg / Oral

5. THP (Trihexyphenidyl)

2 x 2mg / Oral

Efek Terapi

Keterangan

PENGELOMPOKAN DATA
No.
Data Subyektif
Data Objektif
1. Pasien mengatakan, mendengar bisikan-bisikan makhluk gaib dan 1. Pasien tampak pucat dan bingung.
melihat makhluk gaib seperti tuyul dan naga.
2. Pasien di diagnosa lir skizofrenia akut.
2. Keluarga mengatakan pasien pernah mengalami gangguan jiwa dari
masalalu dan mengatakan pengobatan sebelumnya kurang berhasil. 3. Pasien tampak tidur dan telanjang.
3.

4.

5.

6.

7.

Keluarga mengatakan pemberian obat tidak di pantau dan tidak 4. Penampilan pasien tampak berantakan, berminyak, dan bau.
diberikan secara teratur.
5. Pasien saat pembicaraan lambat.
Pasien mengatakan badannya terasa lemas dan tidak nyaman
dengan tubuhnya sekarang setelah minum obat dan berantem 6. Pasien tampak kurang konsentrasi saat berkomunikasi dan tiba-tiba
dengan makhluk gaib.
asik dengan ritual dan doa-doa saat berkomunikasi.
Pasien mengatakan sedih karena anaknya yang paling kecil 7. Pasien tampak sedih dan ketakutan.
dimakan mbahnya (makhluk gaib).
8. Paien afeknya tumpul dan hanya bereaksi jika di beri stimulus kuat
Pasien mengatakan menolong orang-orang / makhluk gaib yang seperti ditanya anak-anak ataupun suaminya.
membisikinya.
9. Interaksi pasien saat wawancara defensive dan kontak mata kurang.
Pasien mengatakan jarang kumpul dengan tetangganya, jika kumpul
hanya seperlunya.
10. Isi piker pasien dipenuhi hal-hal magis.

8.

Pasien mengatakan, lebih sering melaksanakan ritual dan doa-doa 11. Pasien mudah beralih ke ritualnya karena mendengar bisikan
untuk menolong arwah yang membisikinya.
makhluk gaib.

9.

Pasien mengatakan beragama Kristen dan selalu berdoa serta ritual 12. Memori pasien konfabulasi.
untuk menolong arwah yang membisikinya atau yang dilihat.
13. Pasien mengingkari penyakitnya.
Pasien mengatakan, sedang ritual agar tidak dimakan makhluk gaib.
14. Mekanisme koping yang digunakan pasien yaitu isolasi social /
menarik diri.

10.

DAFTAR MASALAH

ANALISA DATA
NO

Data

Masalah Keperawatan

POHON MASALAH

DIAGNOSA KEPERAWATAN

RENCANA KEPERAWATAN

No.

Diagnosa

Tujuan

Kriteria Hasil

Intervensi

CATATAN PERKEMBANGAN

No.

Tanggal

Diagnosa

Implementasi

Evaluasi

RESUME KEPERAWATAN PRAKTIK KLINIK POLI JIWA

RSJD Dr. RM SOEDJARWADI KLATEN
Nama
NIM
Tanggal

:
:
:

A. Data Pasien :
Nama
Umur
Jenis kelamin
Agama
Alamat
No. RM
Tgl masuk RS
Tgl keluar RS
Dx. Medis

:
:
:
:
:
:
:
:
:

B. Keluhan Utama :

C. Riwayat Penyakit Sekarang :

D. Riwayat Penyakit Dahulu :

E. Pemeriksaan Diagnostik :

F. Pemeriksaan Fisik :
Keadaan Umum
:

Kesadaran

Tanda-tanda vital
Suhu
Nadi
Pernafasan
Tekanan darah

:
:
:
:

G. Terapi Yang Diberikan :

H. Diagnosa Keperawatan

RESUME KEPERAWATAN PRAKTIK KLINIK JIWA DI IGD

RSJD Dr. RM SOEDJARWADI KLATEN
Nama
NIM
Tanggal

:
:
:

A. Data Pasien :
Nama
Umur
Jenis kelamin
Agama
Alamat
No. RM
Tgl masuk RS
Tgl keluar RS
Dx. Medis

:
:
:
:
:
:
:
:
:

B. Keluhan Utama :

C. Riwayat Penyakit Sekarang :

D. Riwayat Penyakit Dahulu :

E. Pemeriksaan Diagnostik :

F. Pemeriksaan Fisik :
Keadaan Umum :

Kesadaran

Tanda-tanda vital
Suhu
Nadi
Pernafasan
Tekanan darah

:
:
:
:

G. Terapi Yang Diberikan :

H. Diagnosa Keperawatan