PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

STIKES YARSI PONTIANAK

I. PENGKAJIAN
A. IDENTITAS KLIEN:
1. Nama : (L/P)
2. Umur : tahun
3. Nomor CM :
4. Ruang Rawat :
5. Tanggal MRS :
6. Tanggal Pengkajian :

B. ALASAN MASUK:
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
C. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu? Ya Tidak
2. Pengobatan sebelumnya: Berhasil Kurang Berhasil Tidak Berhasil
3. Trauma:
Jenis Trauma Usia Pelaku Korban Saksi
Aniaya fisik
Aniaya sexual
Penolakan
Kekerasan dalam keluarga
Tindakan kriminal
Lain-lain

Jelaskan No. 1,2,3: ........................................................................................................

........................................................................................................................................
........................................................................................................................................
Diagnosa
Keperawatan:..................................................................................................

4. Anggota keluarga yang gangguan jiwa? Ada Tidak ada

Bila ada : Hubungan keluarga
:...............................................................................
Gejala
:...............................................................................
 Riw. Pengobatan
:...............................................................................
Diagnosa
Keperawatan:..................................................................................................
5. Pengalaman masa lalu yang tidak menyenangkan?
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
Diagnosa
Keperawatan: .................................................................................................

D. PEMERIKSAAN FISIK
1. Tanda Vital : TD:........... mm/Hg N:............x/mt S:............ͦ C P:...............x/mt.
2. Ukur : BB:........... kg TB:.............cm
Jelaskan:...............................................................................................................................
..............................................................................................................................................
Diagnosa
Keperawatan:........................................................................................................

E. PSIKOSOSIAL
1. Genogram: (minimal 3 generasi)

Jelaskan:.........................................................................................................................
........................................................................................................................................
........................................................................................................................................
Diagnosa Keperawatan
: ................................................................................................

2. Konsep Diri:
a. Citra tubuh:..............................................................................................................
.................................................................................................................................
b. Identitas Diri:...........................................................................................................
..................................................................................................................................
c. Peran:.......................................................................................................................
.
 ..................................................................................................................................
d. Ideal
Diri:..................................................................................................................
..................................................................................................................................
e. Harga
Diri:................................................................................................................
..................................................................................................................................
.
Diagnosa
Keperawatan:............................................................................................

3. Hubungan Sosial
a. Orang yang
berarti:...................................................................................................
..................................................................................................................................
b. Peran serta dalam kegiatan
kelompok/masyarakat:..................................................
..................................................................................................................................
c. Hambatan dalam berhubungan dengan orang
lain:...................................................
..................................................................................................................................
Diagnosa
Keperawatan:............................................................................................

4. Spiritual
a. Nilai dan
Keyakinan: ...............................................................................................
..................................................................................................................................
.
b. Kegiatan
Ibadah: ......................................................................................................
..................................................................................................................................
.
Diagnosa
Keperawatan: .................................................................................................

F. STATUS MENTAL
1. Penampilan:
 Bagaimana penampilan klien dalam hal berpakaian, makan, mandi, toileting dan
pemakaian sarana dan prasarana atau instrumentasi dalam mendukung penampilan,
apakah klien:
Tidak rapi
Penggunaan pakaian tidak sesuai
Cara berpakaian tidak seperti biasa
Lain-lain,
jelaskan...................................................................................................
Diagnosa
Keperawatan:..................................................................................................

2. Pembicaraan:
Cepat Keras Gagap Inkoherensi Apatis Lambat
Membisu Tidak mampu memulai pembicaraan
Lain-lain,
jelaskan...................................................................................................
Diangnosa
Keperawatan:................................................................................................

3. Aktivitas Motorik:
Lesu Tegang Gelisah Agitasi TIK Grimasen
Tremor Kompulsif Lain-lain, jelaskan..............................................
Masalah
Keperawatan: ....................................................................................................
4. Afek dan Emosi:
a. Afek: Datar Tumpul Labil Tidak sesuai Lain-lain
Jelaskan:...................................................................................................................
.
Masalah
Keperawatan:..............................................................................................

b. Alam Perasaan (emosi): Sedih Ketakutan Putus asa

Khawatir Gembira berlebihan Lain-lain,
jelaskan.........................
..................................................................................................................................
Diagnosa
Keperawatan:............................................................................................
 5. Interaksi selama Wawancara:
Bermusuhan Tidak kooperatif Mudah tersinggung
Kontak mata kurang Defensif Curiga Lain-lain
Jelaskan:.........................................................................................................................
.......................................................................................................................................
Diagnosa
Keperawatan:..................................................................................................

6. Persepsi & Sensorik:

Apakah ada gangguan: Ada Tidak ada
Halusinasi: Pendengaran Penglihatan Perabaan Pengecapan
Penghidu
Ilusi: Ada Tidak ada Lain-lain,
jelaskan.......................................
Diagnosa
Keperawatan:..................................................................................................

7. Proses Pikir:
a. Proses pikir (arus dan bentuk pikir):
Sirkumtansial Tangensial Blocking Kehilangan asosiasi
Flight of idea Pengulangan pembicaraan Lain-lain,
jelaskan...........
....................................................................................................................................
Diagnosa
Keperawatan:.............................................................................................
b. Isi pikir:
Obsesi Phobia Hipokondria Depersonalisasi
Pikiran magis Ide terkait
Waham: Agama Somatik Kebesaran Curiga
Nihilistik Sisip pikir Siar pikir
Kontrol pikir Lain-lain,
jelaskan.....................................
Diagnosa
Keperawatan: ..............................................................................................
8. Tingkat Kesadaran:
Bingung Sedasi Stupor Lain-lain,
jelaskan...........................
Adakah gangguan orientasi (disorientasi): Waktu Tempat Orang
 Jelaskan: ........................................................................................................................
.
Diagnosa
Keperawatan: .................................................................................................

9. Memori:
Gangguan daya ingat jangka panjang
Gangguan daya ingat jangka menengah
Gangguan daya ingat jangka pendek
Konfabulasi Lain-lain, jelaskan: ..............................................................
Jelaskan: ........................................................................................................................
........................................................................................................................................
Diagnosa
Keperawatan: ................................................................................................

10. Tingkat Konsentrasi dan Berhitung:

Mudah beralih Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhana Lain-lain, jelaskan..............................
Jelaskan: ......................................................................................................................
.....................................................................................................................................
Diagnosa
Keperawatan: ..............................................................................................

11. Kemampuan Penilaian:

Gangguan ringan Gangguan bermakna Lain-lain, jelaskan...............
Jelaskan: ......................................................................................................................
.....................................................................................................................................
Diagnosa
Keperawatan:..................................................................................................

12. Daya Tilik Diri:

Mengingkari penyakit yang diderita
Menyalahkan hal-hal diluar dirinya
Lain-lain,
jelaskan:..................................................................................................
Jelaskan:.........................................................................................................................
.
 Diagnosa
Keperawatan:..................................................................................................

G. KEBUTUHAN PERENCANAAN PULANG

1. Kemampuan klien memenuhi kebutuhan:
Kemampuan memenuhi kebutuhan Ya Tidak
Makanan
Keamanan
Perawatan kesehatan
Pakaian
Transportasi
Tempat tinggal
Keuangan
Lain-lain

Jelaskan:.......................................................................................................................
.
......................................................................................................................................
Diagnosa
Keperawatan:................................................................................................

2. Kegiatan hidup sehari-hari (ADL):

a. Perawatan Diri
Kegiatan hidup sehari-hari Bantuan Total Bantuan Minimal
Mandi
Kebersihan
Makan
Buang air kecil/ BAK
Buang air besar/ BAB
Ganti pakaian

Jelaskan:.......................................................................................................................
.....................................................................................................................................
Diagnosa
Keperawatan:................................................................................................

b. Nutrisi:
1) Apakah anda puas dengan pola makan anda? Puas Tidak puas
Bila tidak puas,
jelaskan:....................................................................................
 2) Apakah anda makan memisahkan diri? Ya Tidak
Bila ya,
jelaskan:.................................................................................................
3) Frekuensi makan sehari: ..........x (kali) dan frekuensi kudapan.............x
(kali).

4) Nafsu makan: meningkat menurun

berlebihan sedikit-sedikit
5) Berat badan: meningkat menurun
Berat badan saat ini: .........kg BB terendah:........kg BB tertinggi:..........kg.
Jelaskan:.............................................................................................................
c. Tidur:
1) Apakah ada masalah tidur? Tidak Ada, jelaskan.........................
2) Apakah merasa segar setelah bangun tidur?
Segar tidak segar, jelaskan...........................................................
3) Apakah ada kebiasaan tidur siang?
Ya, lamanya....... jam. Tidak.
4) Apakah ada yang menolong anda mempermudah tidur?
Ada Tidak ada
Bila ada,
jelaskan:...............................................................................................
5) Tidur malam jam:......... Bangun jam:........... Rata-rata tidur malam:........
jam.
6) Apakah ada gangguan tidur? Sulit untuk tidur
Bangun terlalu pagi Somnambulisme
Terbangun saat tidur Gelisah saat tidur
Berbicara saat tidur Lain-lain, jelaskan.....................
Jelaskan:.............................................................................................................
Diagnosa
Keperawatan:......................................................................................

3. Kemampuan klien dalam hal-hal berikut ini:

a. Mengantisipasi kebutuhan sendiri: Ya Tidak
b. Membuat keputusan berdasarkan keinginan sendiri: Ya Tidak
c. Mengatur penggunaan obat: Ya Tidak
d. Melakukan pemeriksaan kesehatan: Ya Tidak
Jelaskan:.......................................................................................................................
.
 Diagnosa
Keperawatan:................................................................................................

4. Klien memiliki sistem pendukung:

a. Keluarga Ya Tidak
b. Terapis Ya Tidak
c. Teman sejawat Ya Tidak
d. Kelompok sosial Ya Tidak
Jelaskan:.......................................................................................................................
.
Diagnosa
Keperawatan:................................................................................................
5. Apakah klien menikmati saat bekerja, kegiatan produktif atau hobi?
Ya/menikmati Tidak menikmati, jelaskan............................................

H. MEKANISME KOPING
Adaptif
Bicara dengan orang lain
Mampu menyelesaikan masalah
Tekhnik relaksasi
Maladaptif
Aktivitas konstruktif
Minum alkohol
Olah raga
Reaksi lambat/ berlebihan
Lain-lain
Bekerja berlebihan
Menghindar
Mencederai diri
Lain-lain

Jelaskan:..............................................................................................................................
............................................................................................................................................
Diagnosa
Keperawatan: .....................................................................................................

I. MASALAH PSIKOSOSIAL & LINGKUNGAN

Masalah dengan dukungan kelompok,
spesifiknya....................................................
...................................................................................................................................
.
 Masalah berhubungan dengan lingkungan,
spesifiknya.............................................
....................................................................................................................................
.
Masalah dengan pendidikan,
spesifiknya...................................................................
....................................................................................................................................
.
Masalah dengan pekerjaan,
spesifiknya......................................................................
....................................................................................................................................
.
Masalah dengan perumahan,
spesifiknya...................................................................
....................................................................................................................................
.
Masalah dengan ekonomi,
spesifiknya.......................................................................
....................................................................................................................................
.
Masalah dengan pelayanan kesehatan,
spesifiknya....................................................
....................................................................................................................................
.
Masalah lainnya,
spesifiknya......................................................................................
....................................................................................................................................
.
Diagnosa
Keperawatan:......................................................................................................

J. PENGETAHUAN KURANG TENTANG:

Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang
tentang suatu hal:
Penyakit/ gangguan jiwa lain-lain
 Jelaskan:.............................................................................................................................
.
Diagnosa
Keperawatan:......................................................................................................

K. ASPEK MEDIS
Diagnosa Medis
:.......................................................................................................
Terapi Medis
:.......................................................................................................
Diagnosa
Keperawatan:......................................................................................................

II. DAFTAR DIAGNOSA KEPERAWATAN

1. ......................................................................................................................................
2. ......................................................................................................................................
3. ......................................................................................................................................
4. ......................................................................................................................................
5. ......................................................................................................................................
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III. POHON MASALAH

........................., ........-........-
20......
Perawat yang mengkaji

(.....................................................)
IV. RENCANA KEPERAWATAN
Nama Pasien :......................................... No. CM
:...............................
Jenis Kelamin :......................................... Dx. Medis
:...............................
Ruangan :......................................... Unit Keswa
:...............................
No Diagnosa Keperawatan Tujuan & Rencana Tindakan Paraf &
Dx. Nama Prwt
V. IMPLEMENTASI & EVALUASI
Nama Pasien :......................................... No. CM
:...............................
Jenis Kelamin :......................................... Dx. Medis
:...............................
Ruangan :......................................... Unit Keswa
:...............................
Implementasi Evaluasi
Data : S:

O:
Dx :

Implementasi :

A:

RTL : P:
 Ttd

VI. RESUME KEPERAWATAN

Nama Pasien :......................................... No. CM
:...............................
Jenis Kelamin :......................................... Dx. Medis
:...............................
Ruangan :......................................... Unit Keswa
:...............................
Hari/Tanggal :.........................................
Implementasi Evaluasi
Data: S:

O:
Dx:

Implementasi: A:

P:
RTL:

Ttd