Minggu, 16 Oktober 2011

SISTIMATIKA PENYUSUNAN LAPORAN KEPERAWATAN KESEHATAN JIWA oleh: SUIB.S.kep,Ns

FORMAT LAPORAN PENDAHULUAN

A.    KASUS (MASALAH UTAMA)

B.     PROSES TERJADINYA MASALAH
1.    Pengertian masalah utama
2.    Rentang respon
3.    Manifestasi klinik
4.    Kemungkinan penyebab
5.    Kemungkinan akibat bila masalah utama tidak teratasi

C.    MASALAH KEPERAWATAN DAN DATA YANG PERLU DIKAJI

D.    DIAGNOSA KEPERAWATAN (NANDA)

E.     RENCANA TINDAKAN (NCP : NOC, NIC)



FORMAT LAPORAN
STRATEGI PELAKSANAAN (SP)

A.    PROSES KEPERAWATAN
1.      Kondisi klien :
...................................................................................................................................
2.      Diagnosa keperawatan (NANDA) :
...................................................................................................................................
3.      Tujuan (NOC) :
...................................................................................................................................
4.      Tindakan keperawatan (NIC) :
...................................................................................................................................

B.     STRATEGI KOMUNIKASI
1.      Fase Orientasi
Salam terapeutik : ...................................................................................................................................
Evaluasi / validasi data :
...................................................................................................................................
Tujuan :
...................................................................................................................................
Kontrak : 
Topik        : ...............................................................................................................
Waktu      : ...............................................................................................................
Tempat      : ...............................................................................................................
Privasi       : ...............................................................................................................    
               
2.      Fase Kerja (langkah-langkah tindakan keperawatan)
...................................................................................................................................

3.      Fase Terminasi
Evaluasi subyektif dan obyektif :
...................................................................................................................................

Rencana Tindak Lanjut (RTL) :
...................................................................................................................................
Kontrak yang akan datang :
Topik        : ...............................................................................................................
Waktu      : ...............................................................................................................
Tempat      : ...............................................................................................................



FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

Ruang rawat         : ..........                                      Tanggal rawat          : ..........

I.     IDENTITAS
Nama (Inisial)      :
L/P                       :
Umur                    :
Alamat                 :
Pendidikan           :
Agama                  :
No. RM                 :
Tgl Pengkajian     :

II.   ALASAN MASUK
.............................................................................................................................................................................................................................................................................................................................................................................................................................................

III.    FAKTOR PREDIPOSISI
1.        Pernah mengalami gangguan jiwa di masa lalu?   ya    tidak
2.        Pengobatan sebelumnya :  berhasil belum berhasil tidak berhasil
3.        Trauma :
Jenis Trauma
Usia
Pelaku
Korban
Saksi
Aniaya Fisik




Aniaya Seksual




Penolakan




Kekerasan dalam keluarga




Tindakan kriminal




Lain-lain





Jelaskan No 1,2,3 : ......................................................................................................
.....................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................
4.        Adakah anggota keluarga yang mengalami gangguan jiwa? ada tidak ada
Bila ada hubungan keluarga           : ..........................................................................................................................................................................................................................................................................
Gejala                                             : ..........................................................................................................................................................................................................................................................................
Riwayat pengobatan / perawatan   : ..........................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................
5.        Pengalaman masa lalu yang tidak menyenangkan?
..........................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................
IV.    PEMERIKSAAN FISIK
a.       Tanda Vital             : TD: .......... HR: ......... S: .......... RR: .........
b.      Ukur                        : TB:        cm, BB:          kg,   naik turun
c.       Keluhan Fisik          : ada tidak ada
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................
V.    PSIKOSOSIAL
1.        Genogram

                 Keterangan:
                
                 Jelaskan :
..........................................................................................................................................................................................................................................................................
                 Masalah Keperawatan :
...........................................................................................................................................................................................................................................................................

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

3.        Hubungan Sosial
a.    Orang yang berarti :
.................................................................................................................................
b.    Peran serta kegiatan kelompok / masyarakat :
.................................................................................................................................
c.    Hambatan dengan berhubungan dengan orang lain :
.................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................


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

VI.    STATUS MENTAL
1.      Penampilan :
Tidak rapi    
Penggunaan pakaian tidah sesuai    
Cara berpakaian tidak seperti biasanya    
lain-lain
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

2.      Pembicaraan :
Cepat                              Keras                                 Gagap       
Inkoherensi                    Apatis                                            Lambat
Membisu                        Tidak mampu memulai Berbicara  lain-lain
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

3.      Aktivitas Motorik :           
Lesu                               Tegang                               Gelisah      
Agitasi                            TIK                                                  Grimasen
Tremor                            Kompulsif                          lain-lain
                                                      
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

4.      Alam Perasaan (emosi) :
Sedih                              Ketakutan                          Putus asa   
Khawatir                                    Gembira                             Lain-lain   
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

5.       Afek :
Datar                              Tumpul                              Labil         
Tidak sesuai                   Lain-lain   
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

6.      Interaksi selama wawancara :
Bermusuhan                   Tidak Kooperatif               Mudah tersinggung
Kontak mata kurang      Defensif                             Curiga       
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

7.      Persepsi Halusinasi :
Pendengaran                  Penglihatan                        Perabaan   
Pengecapan                    Penghidu   
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

8.       Proses piker :
Sirkumstansial                   Tangensial                        Kehilangan Asosia
Flight of Idea                 Blocking                            Perseverasi
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

9.      Isi Pikir :
Obsesi                            Fobia                                  Hipokondria         
Depersonalisasi              Ide yang terkait                 Pikiran magis
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

10.  Tingkat Kesadaran :
Binggung                       Sedasi                                Stupor
Adakah Gangguan orientasi ( disorientasi ) :         
Waktu                            Orang                                 Tempat
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................




11.  Memori :
Gangguan daya ingat jangka panjang    
Gangguan daya ingat jangka menengah    
Gangguan daya ingat jangka pendek    
Konfabulasi
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

12.  Tingkat Konsentrasi dan Berhitung :
Mudah beralih                                        Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhana         Lain-lain   
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

13.  Kemampuan Penilaian :
Gangguan ringan                                    Gangguan bermakna
Lain-lain
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

14.  Daya Tilik Diri :
Mengingkari penyakit yang diderita    
Menyalahkan hal-hal diluar dirinya    
lain-lain
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................
  
VII. KEBUTUHAN PERSIAPAN PULANG
1.      Kemampuan klien memenuhi kebutuhan:
Kemampuan memenuhi kebutuhan
Ya
Tidak
Mempersiapkan makanan


Menjaga kerapian rumah


Perawatan kesehatan


Mencuci pakaian


Pengaturan keuangan


Belanja 


Transportasi


Lain-lain


Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................
2.      Kegiatan hidup sehari-hari (ADL)
a.    Perawatan diri :
Kegiatan hidup sehari-hari
Bantuan total
Bantuan minimal
Mandi


Kebersihan


Makan


Buang air kecil / BAK


Buang air besar / BAB


Ganti pakaian



Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

b.   Nutrisi :
v  Apakah puas dengan pola makan?
Puas                                Tidak puas                        
v  Apakah makan memisahkan diri?
Ya                                   Tidak                                
v  Frekuensi makan sehari : ..........x
v  Nafsu makan :
Meningkat          Menurun                Berlebihan             Sedikit
v  Berat badan :
Meningkat                      Menurun
BB saat ini : ...........Kg, BB terendah : ..........KG, BB tertinggi : ............KG
Jelaskan: ............................................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................................

c.    Istirahat dan tidur :
v  Apakah ada masalah tidur ?
Ada                    Tidak ada
v  Apakah merasa segar setelah bangun tidur ?
Segar                  Tidak segar
v  Apakah ada kebiasaan tidur siang ?
Ya , lamanya : .........jam             Tidak
v  Apakah ada yang menolong anda mempermudah untuk tidur ?
v  Ada                    Tidak ada
v  Tidur malam jam : .........bangun jam : .........rata-rata tidur malam : ........jam
v  Apakah ada gangguan pola tidur ?
Sulit untuk tidur             Samnambulisme        Gelisah saat tidur
bangun terlalu pagi         Terbangun saat tidur Berbicara saat tidur Jelaskan: ............................................................................................................................................................................................................................................................
Masalah keperawatan :
............................................................................................................................................................................................................................................................

3.      Kemampuan klien dalam hal-hal berikut ini :   
Ø  Mengantisipasi kehidupan sehari-hari :
Ya              Tidak        
Ø  Membuat keputusan berdasarkan keinginan sendiri :
                        Ya              Tidak        
Ø  Mengatur penggunaan obat :
                        Ya              Tidak        
Ø  Melakukan pemeriksaan kesehatan :
Perawatan lanjutan                  Ya                         Tidak        
                        Sistem pendukung                  Ya                         Tidak        
Jelaskan: .........................................................................................................................................................................................................................................................................
Masalah keperawatan :
..........................................................................................................................................................................................................................................................................

VIII.   MEKANISME KOPING
Adaptif
Maladaptif

Berbicara dengan orang lain

Minum alkohol

Mampu menyelesaikan Masalah

Reaksi lambat/berlebih

Teknik relaksasi

Bekerja berlebihan

Aktifitas konstruktif

Menghindar dari orang lain

Olah raga

Mencederai diri

Lain-lain

Lain-lain

Jelaskan: ...................................................................................................................................................................................................................................................................................
Masalah keperawatan :
....................................................................................................................................................................................................................................................................................

IX.    MASALAH PSIKOSOSIAL DAN LINGKUNGAN :
Masalah dengan dukungan kelompok, spesifiknya .....................................................
Masalah berhubungan dengan lingkungan, spesifiknya ..............................................
Masalah dengan Pendidikan, spesifiknya ...................................................................
Masalah dengan Pekerjaan, spesifiknya ......................................................................
Masalah dengan perumahan, spesifiknya ....................................................................
Masalah dengan Ekonomi, spesifiknya .......................................................................
Masalah dengan pelayanan Kesehatan, spesifiknya ....................................................
Masalah keperawatan :
................................................................................................................................................................................................................................................................................................

X.  KURANG PENGETAHUAN TENTANG:
Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang tentang suatu hal?
     Penyakit jiwa              Faktor presipitasi                Sistem pendukung
     Penyakit fisik              Koping                               Obat-obatan
lain-lain
Jelaskan: .............................................................................................................................................................................................................................................................................................
Masalah keperawatan :
................................................................................................................................................................................................................................................................................................



XI.    ASPEK MEDIS
Diagnosa medis : ............................................................................................................................................
Terapi medis :
...........................................................................................................................................
Laboratorium :
...........................................................................................................................................
Masalah keperawatan :
............................................................................................................................................

XII. DATA FOKUS
DATA SUBYEKTIF
DATA OBYEKTIF









XIII.   ANALISA DATA
No
DATA
ETIOLOGI
PROBLEM
1.
Subyektif
............................................................
...........................................................
Obyektif
..........................................................
..........................................................

............................

...........................
2.
Subyektif
............................................................
...........................................................
Obyektif
..........................................................
..........................................................

.............................

............................

XIV.   DAFTAR DIAGNOSA KEPERAWATAN (PRIORITAS)
1.      ....................................................................................................................................
2.      ...................................................................................................................................
3.      ...................................................................................................................................
    
XV.  RENCANA INTERVENSI KEPERAWATAN
NO
TGL/JAM
DIAGNOSA
KEPERAWATAN
NOC
NIC












XVI.   IMPLEMENTASI DAN EVALUASI KEPERAWATAN
NO
TGL/JAM
DIAGNOSA
KEPERAWATAN
IMPLEMENTASI
EVAULASI



S  :
O :
A :
P :
-     Pasien:
-     Perawat:





FORMAT LAPORAN
ANALISIS PROSES INTERAKSI (API)

Inisial Klien                 :                                               Nama Mahasiswa        :
Tahap Penanganan      :                                               Tanggal Interaksi        :
Tujuan Interaksi          :                                               Interaksi Ke                :
Deskripsi Klien           :                                               Waktu                         :

NO
KOMUNIKASI
VERBAL
KOMUNIKASI
NON VERBAL
ANALISA BERPUSAT
PADA KLIEN
ANALISA BERPUSAT
PADA PERAWAT
RASIONAL
1.
P :

P  :
K :
K :
P  :


2.
P :

P  :
K :
K :
P  :


3.
P :

P  :
K :
K :
P  :


4.
P :

P  :
K :
K :
P  :


5.
P :

P  :
K :
K :
P  :





FORMAT LAPORAN
RESUME KEPERAWATAN JIWA

1.        PENGKAJIAN
A.    IDENTITAS KLIEN
Nama (Inisial) :
L/P                  :
Umur               :
Alamat                        :
Pendidikan      :
Agama             :
No. RM            :
Tgl Pengkajian :

B.     ALASAN MASUK
..............................................................................................................................................................................................................................................................................................................................................................................................................................
C.    PEMERIKSAAN FISIK
Keadaan umum           :
TD                               :
Nadi                            :
Respirasi                      :
Suhu                            :
Keluhan fisik               :
D.    DATA FOKUS
DATA SUBYEKTIF
DATA OBYEKTIF








E.     ANALISA DATA

No
DATA
ETIOLOGI
PROBLEM
1.
Subyektif
............................................................
...........................................................
Obyektif
..........................................................
..........................................................

............................

...........................
2.
Subyektif
............................................................
...........................................................
Obyektif
..........................................................
..........................................................

.............................

............................

F.   DAFTAR DIAGNOSA KEPERAWATAN (PRIORITAS)
1.      ....................................................................................................................................
2.      ...................................................................................................................................

G.     RENCANA INTERVENSI KEPERAWATAN

NO
TGL/JAM
DIAGNOSA
KEPERAWATAN
NOC
NIC














H.    IMPLEMENTASI DAN EVALUASI KEPERAWATAN
NO
TGL/JAM
DIAGNOSA
KEPERAWATAN
IMPLEMENTASI
EVAULASI



S  :
O :
A :
P :
-     Pasien  :
-     Perawat:




I.  RENCANA TINDAK LANJUT



FORMAT MAKALAH
SEMINAR ASUHAN KEPERAWATAN

HALAMAN JUDUL
PENGESAHAN
KATA PENGANTAR
DAFTAR ISI
BAB I             : PENDAHULUAN
A.        LATAR BELAKANG
B.        TUJUAN
C.        RUANG LINGKUP
BAB II            : TINJAUAN TEORI
A.        PENGERTIAN
B.        RENTANG RESPON
C.        ETIOLOGI
D.        TANDA DAN GEJALA
E.         FAKTOR PREDISPOSISI DAN PRESIPITASI
F.         TINGKAH LAKU
G.        MEKANISME KOPING
H.        RENCANA INTERVENSI KEPERAWATAN      
BAB III          : TINJAUAN KASUS
A.        PENGKAJIAN
B.        DATA FOKUS
C.        ANALISA DATA
D.        PERUMUSAN DIAGNOSA BERDASARKAN PRIORITAS
E.         PERENCANAAN
F.         IMPLEMENTASI
G.        EVALUASI
BAB IV          : PEMBAHASAN
BAB V             : PENUTUP
DAFTAR PUSTAKA
LAMPIRAN
                       
                                               
FORMAT MAKALAH
TERAPI AKTIVITAS KELOMPOK

A.    PELAKSANAAN
Topik                           :
Sasaran                        :
Hari /Tanggal              :
Jam                              :
Topik                           :

B.     TUJUAN
1.      TUJUAN UMUM           :
...................................................................................................................................
2.      TUJUAN KHUSUS        :
a.    ..............................................................................................................................
b.    ..............................................................................................................................

C.    TINJAUAN TEORI

D.    KLIEN
1.      Karakteristik / Kriteria
2.      Proses Seleksi

E.   PENGORGANISASIAN
1.      Waktu : tanggal, hari, jam, lama tiap langkah kegiatan
2.      Tim Terapis : leader, co leader, fasilitator, observer
3.      Setting tempat
4.      Metode dan media

F.    PROSES PELAKSANAAN
1.      PRA INTERAKSI
2.      ORIENTASI
a.    Salam terapeutik :
b.    Evaluasi / validasi data :
c.    Penjelasan tujuan dan aturan main :
d.   Kontrak : 
Topik   : ...............................................................................................................
Waktu  : ...............................................................................................................
Tempat : .................................................................................................
3.      KERJA
Langkah-langkah kegiatan
4.      TERMINASI
Evaluasi subyektif dan obyektif :
...................................................................................................................................
Rencana Tindak Lanjut (RTL) apa yang akan dilakukan setelah TAK:
...................................................................................................................................
Kontrak yang akan datang :
Topik        : ...............................................................................................................
Waktu      : ...............................................................................................................
Tempat      : ...............................................................................................................

G.  EVALUASI DAN DOKUMENTASI