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Gws Syamil #khitan

Fatigue Test

 

•Fatigue Test

•Uji Psikomotor (Sobriety Test)
•Uji Perasaan Fatigue Subyektif (Kuisioner)
•Uji Hilangnya Kedipan (Flicker Fusion Test)
•Uji Peforma Mental(Buordon Wirsma test)
•Skala Kantuk Epworth

FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

 FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

PROGRAM PROFESI STIKIM

RUANGAN RAWAT : ............................................

TANGGAL DIRAWAT : ............................................

IDENTITAS KLIEN

Inisial                 :                                                  (L/P)

Tanggal Pengkajian         :

Umur                 :

RM No.                 :

Informan                         :

ALASAN MASUK

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

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

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

FAKTOR PREDISPOSISI

Pernah mengalami gangguan jiwa di masa lalu ?

•     Ya                   
•     Tidak 

Pengobatan sebelumnya ?

• Berhasil              
• Kurang berhasil             
• Tidak Berhasil

3.   Aniaya Fisik                pelaku/usia   korban/usia   saksi/usia

• Aniaya seksual

• Penolakan

• Kekerasan dlm keluarga

• Tindakan kriminal

Jelaskan No. 1.2.3  :

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Masalah keperawatan :

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4. Adakah anggota keluarga yang mengalami gangguan jiwa ?

• Ya
• Tidak

        Hubungan Keluarga          Gejala       Riwayat Pengobatan

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Masalah keperawatan  :

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5. Pengalaman masa lalu yang tidak menyenangkan

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Masalah Keperawatan :

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IV. FISIK

1. Tanda Vital :  TD : _____ N : _____  S :_____  P :_____

2. Ukur : TB :_____ BB  :_____

3. Keluhan Fisik :    Ya Tidak

Jelaskan :

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Masalah Keperawatan :

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V. PSIKOSOSIAL

1. Genogram

Ket :

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Masalah keperawatan :

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2. Konsep diri :

a. Gambaran diri :

b. Identitas         :

c. Peran :

d. Ideal diri         :

e. Harga diri :

Masalah Keperawatan :

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3. Hubungan Sosial

a. Orang yang berarti : ......................................................................

b. Peran serta dalam kegiatan Kelompok / Masyarakat :

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c. Hambatan dalam berhubungan dengan orang lain :

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Masalah Keperawatan :

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4. Spiritual

a. Nilai dan keyakinan :

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b. Kegiatan ibadah :

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Masalah keperawatan :

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IV. STATUS MENTAL

1. Penampilan

- Tidak rapih            -Penggunaan pakaian              -Cara berpakaian 

    -Tidak sesuai                    -seperti biasa

Jelaskan :

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Masalah Keperawatan :

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2. Pembicaraan

-Cepat -Keras -Gagap -Inkoheren

-Apatis -Lambat -Membisu,tidak mampu memulai

pembicaraan

Jelaskan :

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Masalah Keperawatan :

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3. Aktifitas Motorik :

Lesu Tegang Gelisah          Agitasi

Tik Grmasen Tremor          Kompulsip

Jelaskan :

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Masalah Keperawatan :

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4. Alam Perasaan

Sedih         Ketakutan Putus asa          Khawatir     Gembira

Jelaskan :

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Masalah Keperawatan :

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5. Afek

Datar Tumpul          Labil   Tidak sesuai

Jelaskan :

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Masalah Keperawatan :

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6. Interaksi Selama Wawancara

Bermusuhan     Tidak kooperatif               Mudah tersinggung

Kontak mata Defensif                 Curiga

Jelaskan :

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Masalah Keperawatan :

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7. Persepsi

  Pendengaran Penglihatan    Perabaan

  Pengecapan Penghidu

Jelaskan :

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Masalah Keperawatan :

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8. Poses Pikir

Sirkumtansial Tangensial   Kehilangan Asosiasi

Flight of ideas Blocking    Pengulangan Pembicaraan

Jelaskan :

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Masalah Keperawatan :

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9. Isi Pikir

Obsesi        Fobia Hipokondria

Depersonalisasi     Ide yang terkait Pikiran magis

Waham

Agama Somatik      Kebesaran           Curiga

Nihilistik Sisip pikir      Siar pikir      Kontrol pikir

Jelaskan :

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Masalah Keperawatan :

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10. Tingkat Kesadaran

Bingung Sedasi Stupor

Waktu Tempat Orang

Jelaskan :

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Masalah Keperawatan :

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11. Memori

  Gangguan daya ingat Gangguan daya ingat

jangka panjang jangka pendek

Gangguan daya ingat saat ini Konfabulasi

Jelaskan :

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Masalah Keperawatan :

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12. Tingkat konsentrasi dan berhitung

  Mudah beralih Tidak mampu       Tidak mampu berhitung 

      sederhana

Jelaskan :

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Masalah Keperawatan :

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13. Kemampuan penilaian

Gangguan ringan Gangguan bermakna

Jelaskan :

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Masalah Keperawatan :

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14. Daya titik diri

Mengingkari penyakit Menyalahkan hal-hal

yang diderita diluar dirinya

Jelaskan :

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Masalah Keperawatan :

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VII. KEBUTUHAN PERSIAPAN PULANG

1. Makan

Bantuan minimal Bantuan total

2. BAB /BAK

Bantuan minimal Bantuan total

Jelaskan :

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Masalah Keperawatan :

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3. Mandi

Bantuan minimal Bantuan total

4. Berpakaian /berhias

Bantuan minimal Bantuan total

5. Istirahat dan tidur

Tidur siang lama : ..................s/d...................

Tidur malam lama :....................s/d...................

Kegiatan sebelum/ sesudah tidur

6. Penggunaan obat

Bantuan minimal Bantuan total

7. Pemeliharaan kesehatan

Perawatan lanjutan Ya Tidak

Perawatan pendukung Ya Tidak

8. Kegiatan didalam rumah

Mempersiapkan makanan Ya Tidak

Menjaga kerapihan rumah Ya Tidak

Mencuci pakaian Ya Tidak

Pengaturan keuangan Ya Tidak

9. Kegiatan diluar rumah

Belanja Ya Tidak

Transportasi Ya Tidak

Lain-lain Ya Tidak

Jelaskan :

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Masalah Keperawatan :

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VIII. MEKANISME KOPING

           Adaptif Maladaptif

Bicara dengan orang lain Minum alkohol

Mampu menyelesaikan masalah Reaksi lambat/ berlebih

Teknik relaksasi Bekerja berlebihan

Aktifitas konstruktip Menghindar

Olah raga Mencedarai diri

Lainnya Lainnya

Masalah Keperawatan :

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IX. MASALAH PSIKOSIS DAN LINGKUNGAN

Masalah dengan dukungan kelompok, spesifik

Masalah berhubungan dengan lingkungan,spesifik

Masalah dengan pendidikan, spesifik

Masalah dengan pekerjaan, spesifik

Masalah dengan perumahan, spesifik

Masalah ekonomi, spesifik

Masalah dengan pelayanan kesehatan, spesifik

Masalah lainnya, spesifik

Masalah Keperawatan :

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X.  PENGETAHUAN KURANG TENTANG :

Penyakit jiwa Sistem pendukung

Faktor presipilisi Penyakit fisik

Koping Obat-obatan

Lainnya

Masalah Keperawatan :

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Analisis Data:

Data:

Masalah:

Subjektif.....................................................

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Subjektif.......................................................

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Objektif........................................................

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XI. ASPEK MEDIK

Diagnosa medik :  ____________________________________

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Terapi medik : ____________________________________

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XII. DAFTAR MASALAH KEPERAWATAN

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XIII. DAFTAR DIAGNOSIS KEPERAWATAN

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......................., ..................

Andi Lukito