ASUHAN KEPERAWATAN JIWA

PADA KLIENDENGAN.
DI RUANG.
RUMAH SAKIT JIWA PROVINSI BALI

OLEH:

NIM:..

PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEDOKTERAN

UNIVERSITAS UDAYANA
2014

PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

DI UNIT RAWAT INAP RUMAH SAKIT JIWA PROVINSI BALI
PROGRAM STUDI ILMU KEPERAWATAN FK UNUD
RUANG RAWAT : ..

Tanggal dirawat : ..

I. IDENTITAS KLIEN
Inisial
: (L/P)
Umur
:
Informan : .

Tanggal Pengkajian : .
No. Rekam Medik : .

II. ALASAN MASUK

III.FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa dimasa lalu ?
ya tidak
2. Pengobatan sebelumnya ?
berhasil
kurang berhasil
tidak berhasil
3. Penolakan dari lingkungan : ya tidak
Jelaskan :

4. Adakah anggota keluarga yang mengalami gangguan jiwa?

ya
tidak
5. Pengalaman masa lalu yang tidak menyenangkan

Masalah Keperawatan : ..
IV.

FISIK
1.

Tanda vital

2.

Ukuran

3.

Keluhan fisik

TD : N : S : P : .
: TB :
Ya

BB : .

Turun

Naik

Tidak

Jelaskan:
.
.
.
Masalah Keperawatan :
V. PSIKOSOSIAL
1. Genogram :

Jelaskan

:...............................................................................................................

..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
Masalah keperawatan :..............................................................................................
2. Konsep Diri
a.

Citra tubuh

:.....................................................................................................

....................................................................................................
....................................................................................................
....................................................................................................
b.

Identitas diri :.....................................................................................................

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

c.

Peran

:......................................................................................................
......................................................................................................
......................................................................................................
.....................................................................................................

d.

Ideal Diri

: ....................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................

e.

Harga Diri

: ....................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................

Masalah keperawatan :.
3. Hubungan Sosial
a. Orang yang berarti

.....................................................................................................................................
.....................................................................................................................................
b. Peran serta dalam kegiatan kelompok/masyarakat:
.....................................................................................................................................
.....................................................................................................................................
c. Hambatan dalam 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 tidak sesuai

Cara pakaian tidak seperti biasanya

Jelaskan:...............................................................................................
.............................................................................................................
.............................................................................................................
................
Masalah keperawatan : ..
2. Pembicaraan
Cepat

Apatis

Kasar

Lambat

Gagap

Membisu

Inkoherensi

tidak mampu memulai pembicaraan

Jelaskan:................................................................................................................
..............................................................................................................................
Masalah keperawatan : ..
3. Aktivitas motorik
Lesu
Gelisah
Tegang
Agitasi

Tik
Tremor
Grimasem Kompulsif

Jelaskan:....................................................................................................................

..................................................................................................................................
.................................................................................................................................
Masalah keperawatan :
4. Alam perasaan
Sedih
Putus Asa Gembira berlebihan
Ketakutan Kuatir
Jelaskan : .....
..
..
Masalah keperawatan :
5. Afek/ emosi
Datar
Tumpul
Labil
Tidak sesuai
Jelaskan :...
..
..
Masalah keperawatan :
6. Interaksi selama wawancara
Bermusuhan
Mudah tersinggung
Defensif
Tidak kooperatif Kontak mata kurang
Curiga
Jelaskan :
.

Masalah keperawatan :

7. Persepsi
Pendengaran
Pengelihatan
Perabaan
Pengecapan
Penghidu
Jelaskan : .
Masalah keperawatan :.
8. Proses pikir
Sirkumstansial
Flight of ideas

Tangensial
Blocking

Kehilangan asosiasi
Pengulangan

pembicaraan/ preservarasi
Jelaskan :.
.
.
Masalah keperawatan :
9. Isi pikir
Obsesi
Hipokondria
Phobia
Depersonalisasi
Waham
Agama
Somatik Kebesaran
Nihilistik Sisip piker Siar piker

Ide yang terkait

Pikiran magis
Curiga
Kontrol piker

Jelaskan :
.
.
Masalah keperawatan :
10. Tingkat kesadaran
Bingung
Sedasi
Stupor
Disorientasi:
Waktu
Tempat
Orang
Jelaskan : .
.
.
Masalah keperawatan :
11. Memori
Gangguan daya ingat jangka panjang

Gangguan daya ingat jangka

pendek
Gangguan daya ingat saat ini
Konfabulasi
Jelaskan : .
..
..
Masalah keperawatan :
12. Tingkat konsentrasi dan berhitung

Mudah beralih
Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhana
Jelaskan :

Masalah keperawatan :

13. Kemampuan penilaian

Gangguan ringan
Gangguan bermakna
Jelaskan :
.
.
Masalah keperawatan : ..

14. Daya tilik diri

Mengingkari penyakit yang diderita

Menyalahkan hal-hal di luar

dirinya
Jelaskan : .
.
.
Masalah keperawatan :.

VI.

KEBUTUHAN PERSIAPAN PULANG

1. Kemampuan klien memenuhi/menyediakan kebutuhan :

a.
b.
c.
d.
e.
f.
g.

Makan : Bantuan minimal Bantuan total

Keamanan : Bantuan minimal Bantuan total
Tempat tinggal : Bantuan minimal Bantuan total
Perawatan kesehatan : Bantuan minimal Bantuan total
Berpakian / berhias: Bantuan minimal
Bantuan total
Transportasi : Bantuan minimal Bantuan total
Uang : Bantuan minimal Bantuan total

2. Kegiatan hidup sehari-hari

a. Perawatan diri : Bantuan minimal Bantuan total
b. Nutrisi :
-

Apakah anda puas dengan pola makan : ya tidak

Apakah anda memisahkan diri : ya tidak

Frekwensi makan perhari :

Frekwensi kudapan perhari

Nafsu makan :

BB :

Diet khusus :

c. Tidur
: ya tidak

apakah ada masalah ?

apakah anda merasa segera setelah bangun tidur ? : ya tidak

apakah ada kebiasaan tidur siang ? : ya tidak

apa yang menolong anda untuk tidur ? ya tidak

Waktu tidur malam : ya tidak

3. Kemampuan klien dalam

-

Mengantisipasi kebutuhan sendiri ? : ya tidak

Membuat keputusan berdasarkan keinginan sendiri : ya tidak

Mengatur penggunaan obat ?

Melakukan pemeriksaan kesehatan (Follow up) : ya tidak

: ya tidak

4. Klien memiliki system pendukung

Keluarga : ya tidak
Profesional/terapis : ya tidak
tidak

Teman Sejawat : ya tidak

Kelompok social : ya

5. Apakah klien menikmati saat bekerja, kegiatan yang menghasilkan atau

hobi : ya tidak
Masalahkeperawatan: .
VIII. MEKANISME KOPING
Adaptif

Maladaptif

Bicara dengan orang lain

Minum alcohol

Mampu menyelesaikan masalah

Relaksaksi lambat berlebih

Teknik relokasi

Berkerja berlebihan

Aktivitas konstruktif

Menghindar

Olahraga

Mensederai diri

Lainya

Lainnya

Alasan : ..
Masalah keperawatan :
IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
Masalah dengan dukungan Kelompok:

.
.
Masalah dengan Lingkungan:

.
Masalah dengan pendidikan :

Masalah dengan Pekerjaan :

Masalah dengan perumahan :

Masalah dengan ekonomi:

.
Masalah dengan pelayanan kesehatan :
.
.
.
Masalah lainnya :
.
.
.................................................................................................................................................
X. PENGETAHUAN KURANG TENTANG :
Penyakit jiwa
Faktor presipitasi
Koping
Lainnya
Sistem pendukung
Penyakit fisik
Obat-obatan
Masalah keperawatan :.............................................................................................................

XI. ASPEK MEDIK

Diagnosa medik :..............................................................................................................

Diagnosis multiaxial :.......................................................................................................

XII. DAFTAR MASALAH KEPERAWATAN

Data
Subyektif :

Obyektif :

Subyektif :

Obyektif :

Subyektif :

Obyektif :

Subyektif :

Obyektif :

Masalah Keperawatan

Subyektif :

Obyektif :

Subyektif :

Obyektif :

Subyektif :

Obyektif :

POHON MASALAH

..
XIII. DIAGNOSA KEPERAWATAN

Bangli
Mahasiswa

()

RENCANA TINDAKAN KEPERAWATAN KESEHATAN JIWA

DI UNIT RAWAT INAP RUMAH SAKIT JIWA PROVINSI BALI

RENCANA TINDAKAN KEPERAWATAN

TINDAKAN
DX. KEP
RASIONAL
TUJUAN
KRITERIA EVALUASI
KEPERAWATAN
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Evaluasi Proses :

Hari/tgl/jam
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Implementasi
Respon klien
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Paraf
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Evaluasi Hasil :

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Hari/ tanggal/

No dx

Diagnosa Keperawatan

Evaluasi

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