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ASUHAN KEPERAWATAN JIWA

ASUHAN KEPERAWATAN JIWA

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RSPAD GATOT SOEBROTO DITKESAD

AKADEMI KEPERAWATAN
ASUHAN KEPERAWATAN JIWA
A. PENGKAJIAN
Tanggal Pengkajian : ______________ Nomor Register : _____________
Ruangan Rawat : ______________ Diagnosa Medis : ______________
Tanggal Dirawat : ______________
1. IDENTITAS KLIEN
Nama : …………..(L/P)
mur : ……………….
!tatus Perkawinan : ……………….
"gama : ……………….
!uku #angsa : ……………….
Pendidikan : ……………….
"lamat : ……………….
!um$er %n&ormasi : ……………….
2. ALASAN MASUK
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3. FAKTOR PREDISPOSISI
a. Perna' mengalami gangguan jiwa di masa lalu ( ( ) )a ( ) Tidak
$. Pengo$atan se$elumn*a. ( ) #er'asil ( ) +urang #er'asil
( ) Tidak #er'asil
,. Pelaku/sia +or$an/sia !aksi/sia
"nia*a -isik ( ) ( ) ( ) ( ) ( ) ( )
"nia*a !eksual ( ) ( ) ( ) ( ) ( ) ( )
Penolakan ( ) ( ) ( ) ( ) ( ) ( )
+ekerasan dalam keluarga ( ) ( ) ( ) ( ) ( ) ( )
Tindakan kriminal ( ) ( ) ( ) ( ) ( ) ( )
Jelaskan a ! "an # $
______________________________________________________________
______________________________________________________________
N " M " : …………………………
N % M : …………………………
______________________________________________________________
Masala% Ke&e'a(a)an :
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
d. "daka' anggota keluarga *g mengalami gangguan jiwa ( ) )a ( ) Tidak
.u$ungan keluarga /ejala Riwa*at 0engo$atan/0erawatan
________________ ______________ _______________________
________________ ______________ _______________________
e. Pengalaman masa lalu *ang tidak men*enangkan
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an ___________________________________________
______________________________________________________________
______________________________________________________________
*. PEMERIKSAAN FISIK
a. Tanda 1ital : TD : _____________ N : _____________
! : _____________ P : _____________
$. kur : T# : _____________ ## : _____________
,. +elu'an &isik : ( ) )a ( ) Tidak
2elaskan :
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an ___________________________________________
______________________________________________________________
______________________________________________________________
+. PSIKOSOSIAL
a. /enogram : /am$arkan
3
Jelaskan $
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Masala% Ke&e'a(a)an _________________________________________
_____________________________________________________________
_____________________________________________________________
$. +onse0 diri
4) /am$aran diri : ___________________________________________
___________________________________________
___________________________________________
___________________________________________
3) %dentitas : ___________________________________________
___________________________________________
___________________________________________
5) Peran : ___________________________________________
___________________________________________
___________________________________________
___________________________________________
6) %deal diri : ___________________________________________
___________________________________________
___________________________________________
___________________________________________
7) .arga diri : __________________________________________
___________________________________________
___________________________________________
___________________________________________
Masala% Ke&e'a(a)an ___________________________________________
______________________________________________________________
_______________________________________________________________
5
,. .u$ungan !osial
4) 8rang *ang $erarti : _________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
3) Peran serta dalam kegiatan kelom0ok/mas*arakat :
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
5) .am$atan dalam $er'u$ungan dengan orang lain :
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Masala% Ke&e'a(a)an ___________________________________________
______________________________________________________________
______________________________________________________________
d. !0iritual
4) Nilai dan ke*akinan :
___________________________________________________________
___________________________________________________________
___________________________________________________________
3) +egiatan i$ada' :
___________________________________________________________
___________________________________________________________
___________________________________________________________
,. STATUS MENTAL
a. Penam0ilan
( ) Tidak ra0i ( ) Penggunaan 0akaian tidak sesuai
( ) 9ara $er0akaian tidak se0erti $iasan*a
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
6
______________________________________________________________
Masala% Ke&e'a(a)an ___________________________________________
_______________________________________________________________
_______________________________________________________________
$. Pem$i,araan
( ) 9e0at ( ) +eras ( ) /aga0 ( ) %nko'eren ( ) "0atis
( ) Lam$at ( ) Mem$isu ( ) Tidak mam0u memulai 0em$i,araan
2elaskan : ________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an ___________________________________________
_______________________________________________________________
_______________________________________________________________
,. "kti1itas Motorik
( ) Lesu ( ) Tegang ( ) /elisa' ( ) "gitasi
( ) Tik ( ) /rimasen ( ) Tremor ( ) +om0ulsi&
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
d. "lam 0erasaan
( ) !edi' ( ) +etakutan ( ) Putus asa
( ) +'awatir ( ) /em$ira $erle$i'an
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
7
______________________________________________________________
e. "&ek
( ) Datar ( ) Tum0ul ( ) La$il ( ) Tidak sesuai
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
&. %nteraksi selama wawan,ara
( ) #ermusu'an ( ) Tidak koo0erati& ( ) Muda' tersinggung
( ) +ontak mata kurang ( ) De&ensi& ( ) 9uriga
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
g. Perse0si
.alusinasi
( ) Pendengaran ( ) Pengli'atan ( ) Pera$aan
( ) Penge,a0an ( ) Peng'idu
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
:
'. Proses Pikir
( ) !irkumstansial ( ) Tangensial ( ) +e'ilangan asosiasi
( ) -lig't o& ideas ( ) #lo,king
( ) Pengulangan 0em$i,araan/0erse1arasi
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
i. %si 0ikir
( ) 8$sesi ( ) -o$ia ( ) .i0okondria
( ) De0ersonalisasi ( ) %de *ang terkait ( ) Pikiran magis
;a'am :
( ) "gama ( ) !omatik ( ) +e$esaran ( ) 9uriga
( ) Ni'ilistik ( ) !isi0 0ikir ( ) !iar 0ikir ( ) +ontrol 0ikir
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
j. Tingkat +esadaran
( ) #ingung ( ) !edasi ( ) !tu0or
Disorientasi :
( ) ;aktu ( ) Tem0at ( ) 8rang
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
<
______________________________________________________________
a. Memori
( ) /angguan da*a ingat jangka 0anjang
( ) /angguan da*a ingat jangka 0endek
( ) /angguan da*a ingat saat ini ( ) +on&a$ulasi
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
$. Tingkat konsentrasi dan $er'itung
( ) Muda' $erali' ( ) Tidak mam0u $erkonsentrasi
( ) Tidak mam0u $er'itung seder'ana
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
,. +emam0uan Penilaian
( ) /angguan ringan ( ) /angguan $ermakna
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
_____________________________________________________________
d. Da*a tilik diri
( ) Mengingkari 0en*akit *ang di derita
( ) Men*ala'kan 'al='al di luar dirin*a
2elaskan : _________________________________________
______________________________________________________________
>
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
-. KEBUTUHAN PERSIAPAN PULANG
a. Makan
( ) #antuan minimal ( ) #antuan total
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
$. #"#/#"+
( ) #antuan minimal ( ) #antuan total
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
,. Mandi
( ) #antuan minimal ( ) #antuan total
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
5. #er0akaian/$er'ias
( ) #antuan minimal ( ) #antuan total
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
6. %stira'at dan tidur
( ) Tidur siang lama : ……………………… s/d ………………….
( ) Tidur malam lama : ……………………... s/d ……………………
( ) +egiatan se$elum/sesuda' tidur
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
7. Penggunaan o$at
( ) #antuan minimal ( ) #antuan total
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
?
:. Pemeli'araan kese'atan )a Tidak
Perawatan lanjutan ( ) ( )
!istem 0endukung ( ) ( )
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
<. +egiatan di dalam ruma' )a Tidak
Mem0ersia0kan makanan ( ) ( )
Menjaga kera0i'an ruma' ( ) ( )
Men,u,i 0akaian ( ) ( )
Pengaturan keuangan ( ) ( )
_____________________________________________________________
_____________________________________________________________
>. +egiatan di luar ruma' )a Tidak
#elanja ( ) ( )
Trans0ortasi ( ) ( )
Lain @ lain ( ) ( )
2elaskan : _______________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
______________________________________________________________
.. MEKANISME KOPING
A"a/)0/ Mala"a/)0/
( ) #i,ara dengan orang lain ( ) Minum "lko'ol
( ) Mam0u men*elesaikan masala' ( ) Reaksi lam$at / $erle$i'
( ) Teknik relaksasi ( ) #ekerja $erle$i'an
( ) "kti1itas konstrukti& ( ) Meng'indar
( ) 8la'raga ( ) Men,ederai diri
( ) Lainn*a ………………………. ( ) Lainn*a ……………….
2elaskan : _________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
4A
Masala% Ke&e'a(a)an __________________________________________
______________________________________________________________
1. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
( ) Masala' dengan dukungan kelom0okB s0esi&ik _____________________
________________________________________________________________
( ) Masala' $er'u$ungan dengan lingkunganB s0esi&ik _________________
________________________________________________________________
( ) Masala' dengan 0endidikanB s0esi&ik ____________________________
________________________________________________________________
( ) Masala' dengan 0ekerjaanB s0esi&ik _____________________________
________________________________________________________________
( ) Masala' dengan 0eruma'anB s0esi&ik ____________________________
________________________________________________________________
( ) Masala' ekonomiB s0esi&ik ____________________________________
________________________________________________________________
( ) Masala' dengan 0ela*anan kese'atanB s0esi&ik _____________________
________________________________________________________________
( ) Masala' lainn*aB s0esi&ik _____________________________________
________________________________________________________________
( ) Masala' dengan dukungan lingkunganB s0esi&ik ___________________
________________________________________________________________
Masala% Ke&e'a(a)an ____________________________________________
________________________________________________________________
________________________________________________________________
12. PENGETAHUAN KURANG TENTANG $
( ) Pen*akit 2iwa ( ) !istem 0endukung ( ) -aktor 0resi0itasi
( ) Pen*akit &isik ( ) +o0ing ( ) 8$at=o$atan ( ) Lainn*a
Masala% Ke&e'a(a)an ____________________________________________
________________________________________________________________
________________________________________________________________
11. ASPEK MEDIK
Diagnosa medik :
33333333333333333333333333333333333333333333333333333333333333333
333333333333333333333333333333333333333333333333333333333333333
Tera0i medik :
3333333333333333333333333333333333333333333333333333333333333333
________________________________________________________________
2akartaB ………………………..3A4A
Ma'asiswa
44
(……………………………)
12. ANALISA DATA
In0)0al Na4a $ 333333333333 R5an6an $ 333333333333 N7. RM $ 3333333333
TANGGAL 8 JAM DATA FOKUS
MASALAH
KEPERAWATAN
43
13. POHON MASALAH
45
B. DAFTAR DIAGNOSA KEPERAWATAN
46
2akartaB …………………
Ma'asiswa
(………………………)
47
9. REN9ANA TINDAKAN KEPERAWATAN
INITIAL KLIEN $ __________ RUANGAN $ ___________ RM NO $ __________
N7
D
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D0a6n7sa
Ke&e'a(a)
an
Pe'en#anaan
T5;5an
K'0)e'0a
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T0n"akan
Ke&e'a(a)an














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

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