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Format Pengkajian Keperawatan Jiwa

Format Pengkajian Keperawatan Jiwa

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Published by Anisa Rooses

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Published by: Anisa Rooses on Oct 04, 2011
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05/22/2013

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FORMAT PENGKAJIANASUHAN KEPERAWATAN JIWASTIKES HANG TUAH SURABAYA
 Nama mahasiswa : .................................................................................................................................. NIM : ..................................................................................................................................Ruangan : ..................................................................................................................................Pengkajian diambil : ..................................................................................................................................Diagnosa medis : ..................................................................................................................................
I.IDENTITAS KLIEN
 No. RM : Nama :Inisial : L / PUmur : .......... tahun
II.ALASAN MASU
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
III.FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu?a. Ya b. Tida2. Pengobatan sebelumnya?a. Berhasil b. Kurang berhasil c. Tidak berhasil3. Faktor :
Aniaya fisik a. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun
Aniaya seksuala. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun
Penolakana. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun
Kekerasan dalam rumah tanggaa. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun
Tindakan kriminala. Pelaku : ..................................................................................... Usia : ............. tahun b. Korban : ..................................................................................... Usia : ............. tahunc. Saksi : ..................................................................................... Usia : ............. tahun
Jelaskan no. 1, 2, 3.........................................................................................................................................................................................................................................................................................................................................................................................................................................................
 
Masalah keperawatan.........................................................................................................................................................................................................................................................................................................................................................................................................................................................
 
4. Adakah anggota keluarga yang mengalami gangguan jiwa?a. Ya b. Tida
 Bila ada isi dibawah ini :
Hubungan keluargaa. .............................. b. ..............................Gejalaa. .............................. b. ..............................Riwayat pengobatan/perawatana. .............................. b. ..............................Masalah keperawatan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................5. Pengalaman masa lalu yang tidak menyenangkan...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
IV.PENGKAJIAN FISI
1. Tanda VitalTD : ………… mm/hg N : ………… x/menit S : ………… °C P : ………… x/menit2. Ukur tubuhTB : ………… cm BB : ………… kg3. Keluhan Fisik a. Ya b. TidaJelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
V.PSIKOSOSIAL
1. Genogram :Jelaskan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah keperawatan :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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Chomell Bercahaya Mayha added this note
terima kasih atas format pengkajiannya.,ini sangat bermanfaat bagi saya.

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