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PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

RUANG RAWAT: TANGGAL DIRAWAT:


I. IDENTITAS KLIEN
Inisial :________________________(L/P) TGL :____________________
Umur :________________________ RM No. :____________________
Alamat :________________________ Pekerjaan :____________________
Informan :________________________
II. ALASAN MASUK
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III. FAKTOR PRESIPITASI/ RIWAYAT PENYAKIT SEKARANG
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IV. FAKTOR PREDISPOSISI
 RIWAYAT PENYAKIT LALU
1. Pernah mengalami gangguan jiwa di masa lalu? ya tidak
Bila ya
jelaskan_____________________________________________________________
___________________________________________________________________
2. Pengobatan sebelumnya Berhasil Kurang Berhasil Tidak
Berhasil
3. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
ya tidak
Bila ya
jelaskan_____________________________________________________________
___________________________________________________________________
 RIWAYAT PSIKOSOSIAL
Pelaku/ usia Korban/ usia Saksi/ usia
1. Aniaya fisik
2. Aniaya seksual
3. Penolakan
4. Kekerasan dalam keluarga
5. Tindakan kriminal

Jelaskan :________________________________________________________
___________________________________________________________________
6. Pengalaman masa lalu lain yang tidak menyenangkan (bio, psiko, sosio,
kultural, spiritual):
___________________________________________________________________
___________________________________________________________________
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Masalah keperawatan :____________________________________________
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7. Kesan Kepribadian klien: extrovert introvert
lain_lain:___________
 RIWAYAT PENYAKIT KELUARGA
1. Adakah anggota keluarga yang mengalami gangguan jiwa? ya
tidak
Hubungan keluarga :__________________________________________________
Gejala :__________________________________________________
Riwayat Pengobatan/ perawatan :______________________________________
Masalah keperawatan :__________________________________________________
V. STATUS MENTAL
1. Penampilan
tidak rapi penggunaan pakaian tidak sesuai
Cara berpakaian tidak seperti biasanya
Jelaskan :________________________________________________________
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Masalah keperawatan : __________________________________________________
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2. Kesadaran
 Kwantitatif/ penurunan kesadaran]
compos mentis apatis/ sedasi somnolensia
sopor subkoma koma
 Kwalitatif
tidak berubah berubah
meninggi gangguan tidur: sebutkan______________________
hipnosa disosiasI: sebutkan___________________________
Jelaskan :________________________________________________________
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3. Disorientasi
waktu tempat orang
Jelaskan :________________________________________________________
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Masalah keperawatan : __________________________________________________
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4. Aktivitas Motorik/ Psikomotor
Kelambatan:
hipokinesia, hipoaktivitas sub stupor katatonik
katalepsi flexibilitas serea
Peningkatan:
hiperkinesia, hiperaktivitas gaduh gelisah katatonik
TIK grimase tremor gagap
stereotipi mannarism katalepsi akhopraxia
command automatism atomatisma nagativisme
reaksi konversi verbigerasi berjalan kaku/ rigit
kompulsif lain-2 sebutkan:________________________________
5. Afek/ Emosi
adequat tumpul dangkal/ datar labil
inadequat anhedonia marasa kesepian eforia
ambivalen apati marah depresif/ sedih
cemas: ringan sedang berat panik
Jelaskan :________________________________________________________
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Masalah keperawatan : __________________________________________________
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6. Persepsi
halusinasi ilusi depersonalisasi derealisasi
Macam Halusinasi
pendengaran penglihatan perabaan
pengecapan penghidu/ pembauan lain-lain, sebutkan...................
Jelaskan :________________________________________________________
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Masalah keperawatan : __________________________________________________
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7. Proses Pikir
 Arus Pikir
koheren inkoheren asosiasi longgar
fligt of ideas blocking pengulangan pembicaraan/ persevarasi
tangansial sirkumstansiality logorea
neologisme bicara lambat bicara cepat irelevansi
main kata-kata afasi assosiasi bunyi lain2 sebutkan.............
Jelaskan :________________________________________________________
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Masalah keperawatan : _______________________________________________
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 Isi Pikir
obsesif ekstasi fantasi
bunuh diri ideas of reference pikiran magis
alienasi isolaso sosial rendah diri
preokupasi pesimisme fobia sebutkan.........................
waham: sebutkan jenisnya
agama somatik, hipokondrik kebesaran curiga
nihilistik sisip pikir siar pikir kontrol pikir
kejaran dosa
Jelaskan :________________________________________________________
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Masalah keperawatan : _______________________________________________
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 Bentuk Pikir
realistik nonrealistik
autistik dereistik
Jelaskan :________________________________________________________
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8. Memori
gangguan daya ingat jangka panjang gangguan daya ingat jangka pendek
gangguan daya ingat saat ini amnesia, sebutkan.........................
paramnesia, sebutkan jenisnya........................................................
hipermnesia, sebutkan ...................................................................
Jelaskan :________________________________________________________
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Masalah keperawatan : __________________________________________________
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9. Tingkat Konsentrasi dan Berhitung
mudah beralih tidak mampu berkonsentrasi
tidak mampu berhitung sederhana
Jelaskan :________________________________________________________
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Masalah keperawatan : __________________________________________________
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10. Kemampuan Penilaian
gangguan ringan gangguan bermakna
Jelaskan :________________________________________________________
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Masalah keperawatan : _________________________________________________
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11. Daya Tilik Diri/ Insight
mengingkari penyakit yang diderita menyalahkan hal-hal diluar dirinya
Jelaskan :________________________________________________________
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Masalah keperawatan : _________________________________________________
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12. Interaksi selama Wawancara
bermusuhan tidak kooperatif mudah tersinggung
kontak mata kurang defensif curiga
Jelaskan :________________________________________________________
____________________________________________________________________
Masalah keperawatan : _________________________________________________
VI. FISIK
1. Keadaan umum
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2. Tanda vital:
TD:___________ N:___________ S:_____________ P:_____________
3. Ukur:
TB:___________ BB:__________ turun naik
4. Keluhan fisik: tidak ya
jelaskan..................................................................
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5. Pemeriksaan fisik:
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Jelaskan :________________________________________________________
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Masalah keperawatan : __________________________________________________
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VII. PENGKAJIAN PSIKOSOSIAL (sebelum dan sesudah sakit)
1. Konsep Diri
a. Citra tubuh
:________________________________________________________
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b. Identitas :__________________________________________________
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c. Peran :________________________________________________________
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d. Ideal diri
:________________________________________________________
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e. Harga diri
:________________________________________________________
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Masalah keperawatan : _______________________________________________
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2. Genogram

3. Hubungan Sosial
a. Hubungan terdekat :
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b. Peran serta dalam 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 dan kultural
a. Nilai dan keyakinan
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b. Konflik nilai/ keyakinan/ budaya
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c. Kegiatan ibadah
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Masalah keperawatan :____________________________________________
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VIII. AKTIVITAS SEHARI-HARI (ADL)
1. Makan
Bantuan minimal Sebagian Bantuan total
2. BAB/BAK
Bantuan minimal Sebagian Bantuan total
3. Mandi
Bantuan minimal Sebagian Bantuan total
4. Berpakaian/berhias
Bantuan minimal Sebagian Bantuan total
5. Istirahat dan tidur
Tidur siang lama : ______________________ s/d_________________________
Tidur malam lama: _____________________ s/d_________________________
Aktivitas sebelum / sedudah tidur : _________________ s/d ________________
6. Pengginaan obat
Bantuan minimal Sebagian Bantuan total
7. Pemeliharaan kesehatan
Perawatan Lanjutan Ya Tidak
Sistem pendukung Ya Tidak
8. Aktivitas di dalam rumah
Mempersiapkan makanan Ya Tidak
Menjaga kerapihan rumah Ya Tidak
Mencuci pakaian Ya Tidak
Pengaturan keuangan Ya Tidak
9. Aktivitas di luar rumah
Belanja Ya Tidak
Transportasi Ya Tidak
Lain-lain Ya Tidak
Jelaskan :________________________________________________________
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Masalah keperawatan : _________________________________________________
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IX. MEKANISME KOPING
Adatif Maladaptif
Bicara dengan orang lain Minum Alkohol
Mampu menyelesaikan masalah Reaksi lambat / berlebih
Teknik relokasi Bekerja berlebihan
Aktivitas konstruktif Menghindar
Olah raga Mencederai diri
Lainnya ...................... Lainnya ......................
Masalah keperawatan : ___________________________________________________
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X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
Masalah dengan dukungan kelompok, uraikan
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Masalah berhubungan dengan lingkungan, uraikan
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Masalah dengan pendidikan, uraikan
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Masalah dengan pekerjaan, uraikan
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Masalah dengan perumahan, uraikan
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Masalah dengan ekonomi, uraikan
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Masalah dengan pelayanan kesehatan, uraikan
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Masalah lainnya, uraikan
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Masalah keperawatan : ___________________________________________________
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XI. KURANG PENGETAHUAN TENTANG
Penyakit jiwa Sistem pendukung
Faktor presiptasi Penyakit fisik
Koping Obat-obatan
Lainnya __________________________
Masalah keperawatan : ___________________________________________________
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XII. ASPEK MEDIK
Diagnosa medik : _______________________________________________________
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Terapi medik : _______________________________________________________
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XIII. DAFTAR MASALAH KEPERAWATAN
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XIV. ANALISA DATA
No DATA MASALAH
XV. POHON MASALAH
XVI. DIAGNOSA KEPERAWATAN
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MAHASISWA

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DAFTAR DIAGNOSA KEPERAWATAN
(Berdasarkan prioritas)

Ruang :
Nama Pasien :
No. Register :
No. TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TANDA
Dx MUNCUL TERATASI TANGAN
IMPLEMENTASI DAN EVALUASI
KEPERAWATAN KESEHATAN JIWA

Nama : _________________Ruangan : _____________________RM No. : ___________


NO Tanggal IMPLEMENTASI
EVALUASI
Dx & Jam KEPERAWATAN