RSPAD GATOT SOEBROTO DITKESAD

N A M A : …………………………
NIM
: …………………………

AKADEMI KEPERAWATAN

ASUHAN KEPERAWATAN JIWA
A.

PENGKAJIAN

Tanggal Pengkajian : ______________

Nomor Register : _____________

Ruangan Rawat

: ______________

Diagnosa Medis : ______________

Tanggal Dirawat

: ______________

1. IDENTITAS KLIEN
Nama

: …………..(L/P)

Umur

: ……………….

Status Perkawinan : ……………….
Agama

: ……………….

Suku Bangsa

: ……………….

Pendidikan

: ……………….

Alamat

: ……………….

Sumber Informasi

: ……………….

2. ALASAN MASUK
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3. FAKTOR PREDISPOSISI
a. Pernah mengalami gangguan jiwa di masa lalu ? (
b. Pengobatan sebelumnya. (
(
c.

) Berhasil

(

) Ya (

) Tidak

) Kurang Berhasil

) Tidak Berhasil
Pelaku/Usia Korban/Usia Saksi/Usia

Aniaya Fisik

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Aniaya Seksual

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Penolakan

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Kekerasan dalam keluarga

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Tindakan kriminal

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Jelaskan a, b dan c

:

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Ukur Jelaskan ) Ya ( ) Tidak : ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan ___________________________________________ ______________________________________________________________ ______________________________________________________________ 5. Adakah anggota keluarga yg mengalami gangguan jiwa ( ) Ya ( ) Tidak Hubungan keluarga Gejala Riwayat pengobatan/perawatan ________________ ______________ _______________________ ________________ ______________ _______________________ e. PSIKOSOSIAL a. Keluhan fisik : ( b. PEMERIKSAAN FISIK a. Pengalaman masa lalu yang tidak menyenangkan ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan ___________________________________________ ______________________________________________________________ ______________________________________________________________ 4.______________________________________________________________ Masalah Keperawatan : ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ d. Tanda vital : TD : _____________ N : _____________ S : _____________ P : _____________ : TB : _____________ BB : _____________ c. Genogram : 2 Gambarkan .

Jelaskan : _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Masalah Keperawatan _________________________________________ _____________________________________________________________ _____________________________________________________________ b. Konsep diri 1) Gambaran diri : ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ 2) Identitas : ___________________________________________ ___________________________________________ ___________________________________________ 3) Peran : ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ 4) Ideal diri : ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Harga diri : __________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Masalah Keperawatan ___________________________________________ ______________________________________________________________ _______________________________________________________________ 3 .

STATUS MENTAL a. Spiritual 1) Nilai dan keyakinan : ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 2) Kegiatan ibadah : ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 6.c. Hubungan Sosial 1) Orang yang berarti : _________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 2) Peran serta dalam kegiatan kelompok/masyarakat : ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 3) Hambatan dalam berhubungan dengan orang lain : ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Masalah Keperawatan ___________________________________________ ______________________________________________________________ ______________________________________________________________ d. Penampilan ( ) Tidak rapi ( ) Cara berpakaian tidak seperti biasanya Jelaskan ( ) Penggunaan pakaian tidak sesuai : _________________________________________ ______________________________________________________________ ______________________________________________________________ 4 .

Aktivitas Motorik ( ) Lesu ( ) Tegang ( ) Gelisah ( ) Agitasi ( ) Tik ( ) Grimasen ( ) Tremor ( ) Kompulsif Jelaskan : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ d.______________________________________________________________ Masalah Keperawatan ___________________________________________ _______________________________________________________________ _______________________________________________________________ b. Pembicaraan ( ) Cepat ( ( ) Lambat ( ) Keras ( ) Membisu ( Jelaskan ) Gagap ( ) Inkoheren ( ) Apatis ) Tidak mampu memulai pembicaraan : ________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan ___________________________________________ _______________________________________________________________ _______________________________________________________________ c. Alam perasaan ( ) Sedih ( ) Ketakutan ( ) Khawatir ( ) Gembira berlebihan Jelaskan ( ) Putus asa : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ 5 .

Persepsi Halusinasi ( ) Pendengaran ( ) Penglihatan ( ) Pengecapan ( ) Penghidu Jelaskan ( ) Perabaan : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ 6 . Afek ( ) Datar ( ) Tumpul Jelaskan ( ) Labil ( ) Tidak sesuai : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ f.______________________________________________________________ e. Interaksi selama wawancara ( ) Bermusuhan ( ) Kontak mata kurang Jelaskan ( ) Tidak kooperatif ( ) Defensif ( ) Mudah tersinggung ( ) Curiga : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ g.

h. Isi pikir ( ) Obsesi ( ) Fobia ( ) Hipokondria ( ) Depersonalisasi ( ) Ide yang terkait ( ) Pikiran magis Waham : ( ) Agama ( ) Somatik ( ) Kebesaran ( ) Curiga ( ) Nihilistik ( ) Sisip pikir ( ) Siar pikir ( ) Kontrol pikir Jelaskan : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ j. Proses Pikir ( ) Sirkumstansial ( ) Tangensial ( ) Flight of ideas ( ) Blocking ( ) Pengulangan pembicaraan/persevarasi Jelaskan ( ) Kehilangan asosiasi : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ i. Tingkat Kesadaran ( ) Bingung ( ) Sedasi ( ) Stupor ( ) Tempat ( ) Orang Disorientasi : ( ) Waktu Jelaskan : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ 7 .

Memori ( ) Gangguan daya ingat jangka panjang ( ) Gangguan daya ingat jangka pendek ( ) Gangguan daya ingat saat ini Jelaskan ( ) Konfabulasi : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ b. ( Kemampuan Penilaian ) Gangguan ringan Jelaskan ( ) Gangguan bermakna : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ _____________________________________________________________ d. Daya tilik diri ( ) Mengingkari penyakit yang di derita ( ) Menyalahkan hal-hal di luar dirinya Jelaskan : _________________________________________ ______________________________________________________________ 8 .______________________________________________________________ a. Tingkat konsentrasi dan berhitung ( ) Mudah beralih ( ) Tidak mampu berhitung sederhana Jelaskan ( ) Tidak mampu berkonsentrasi : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ c.

( ) Tidur malam lama : ……………………. ( Penggunaan obat ) Bantuan minimal ( ) Bantuan total _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 9 . KEBUTUHAN PERSIAPAN PULANG a. Makan ( ) Bantuan minimal ( ) Bantuan total _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ b.______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ 7.. Istirahat dan tidur ( ) Tidur siang lama : ……………………… s/d ………………….. Berpakaian/berhias ( ) Bantuan minimal ( ) Bantuan total _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 4. BAB/BAK ( ) Bantuan minimal ( ) Bantuan total _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ c. s/d …………………… ( ) Kegiatan sebelum/sesudah tidur _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 5. Mandi ( ) Bantuan minimal ( ) Bantuan total _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 3.

Pemeliharaan kesehatan Ya Tidak Perawatan lanjutan ( ) ( ) Sistem pendukung ( ) ( ) _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 7. ( ) Lainnya ……………….6. Jelaskan : _________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 10 . Kegiatan di dalam rumah Ya Tidak Mempersiapkan makanan ( ) ( ) Menjaga kerapihan rumah ( ) ( ) Mencuci pakaian ( ) ( ) Pengaturan keuangan ( ) ( ) _____________________________________________________________ _____________________________________________________________ 8. Kegiatan di luar rumah Ya Tidak Belanja ( ) ( ) Transportasi ( ) ( ) Lain – lain ( ) ( ) Jelaskan : _______________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Masalah Keperawatan __________________________________________ ______________________________________________________________ ______________________________________________________________ 8. MEKANISME KOPING Adaftif Maladaftif ( ) Bicara dengan orang lain ( ) Minum Alkohol ( ) Mampu menyelesaikan masalah ( ) Reaksi lambat / berlebih ( ) Teknik relaksasi ( ) Bekerja berlebihan ( ) Aktivitas konstruktif ( ) Menghindar ( ) Olahraga ( ) Mencederai diri ( ) Lainnya ……………………….

PENGETAHUAN KURANG TENTANG : ( ) Penyakit Jiwa ( ) Sistem pendukung ( ) Faktor presipitasi ( ) Penyakit fisik ( ) Koping ( ) Obat-obatan ( ) Lainnya Masalah Keperawatan ____________________________________________ ________________________________________________________________ ________________________________________________________________ 11. spesifik _____________________ ________________________________________________________________ ( ) Masalah lainnya. spesifik _____________________________________ ________________________________________________________________ ( ) Masalah dengan dukungan lingkungan.2010 Mahasiswa 11 . ………………………. spesifik _____________________ ________________________________________________________________ ( ) Masalah berhubungan dengan lingkungan. spesifik _________________ ________________________________________________________________ ( ) Masalah dengan pendidikan. ASPEK MEDIK Diagnosa medik : _________________________________________________________________ _______________________________________________________________ Terapi medik : ________________________________________________________________ ________________________________________________________________ Jakarta. MASALAH PSIKOSOSIAL DAN LINGKUNGAN ( ) Masalah dengan dukungan kelompok. spesifik ____________________________________ ________________________________________________________________ ( ) Masalah dengan pelayanan kesehatan.Masalah Keperawatan __________________________________________ ______________________________________________________________ 9. spesifik ___________________ ________________________________________________________________ Masalah Keperawatan ____________________________________________ ________________________________________________________________ ________________________________________________________________ 10.. spesifik ____________________________ ________________________________________________________________ ( ) Masalah ekonomi. spesifik _____________________________ ________________________________________________________________ ( ) Masalah dengan perumahan. spesifik ____________________________ ________________________________________________________________ ( ) Masalah dengan pekerjaan.

(……………………………) 12. RM : __________ TANGGAL / JAM DATA FOKUS 12 MASALAH KEPERAWATAN . ANALISA DATA Initial Nama : ____________ Ruangan : ____________ No.

13. POHON MASALAH 13 .

DAFTAR DIAGNOSA KEPERAWATAN 14 .B.

RENCANA TINDAKAN KEPERAWATAN INITIAL KLIEN : __________ RUANGAN : ___________ RM NO : __________ No Diagnosa Perencanaan Kriteria Tindakan D Keperawat Tujuan Evaluasi Keperawatan X an Jakarta.C. ………………… Mahasiswa (………………………) 15 .

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