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PENGKAJIAN KEPERAWATAN JIWA

KESEHATAN JIWA

Tanggal MRS : 6/01/2017


Tanggal dirawat di ruangan : 14/01/2017
Tanggal pengkajian : 16/01/2017
Ruang rawat : Ruang Kakak Tua

I. IDENTITAS KLIEN
Nama : Sdr. MRP
Umur : 23 Tahun
Alamat : Bojonegoro
Pendidikan : SMK/Multimedia
Agama : Islam
Status : Belum Menikah
Pekerjaan : Tidak Bekerja
Jenis kelamin : Laki-Laki
No. CM : 1162xx

II. ALASAN MASUK


a. Data primer
Ds: Px mengatakan mengenal teman-temannya sekamar, tau nama mereka, namun
tidak pernah memulai mengajak bicara lebih dulu dengan mereka
Do: Px mampu menyebutkan beberapa nama teman sekamarnya, tatapan mata kurang,
bicara kooperatif dan koheren, afek datar
b. Data sekunder
Menurut data perawat jaga, px didiagnosa masuk dengan F20.1.3 (Skizofrenia
Hebefrenik Berkelanjutan)
c. Keluhan utama saat pengkajian
Px mengeluh merasabsesak sejak pindah di ruangan kakak tua. Sebelum di ruang ini ia

tinggal di ruang perkutut dan ia lebih suka disana karena tidak sesak. Px juga

mengeluh badannya sakit semua.

III. RIWAYAT PENYAKIT SEKARANG


Px mengatakan dia dibawa kesini oleh bapaknya mengira Sdr. MRP gila. Px mengaku
mengenal teman-teman sekamarnya , tau nama-nama mereka namun tidak mau
berinteraksi dengan mereka karena
IV. RIWAYAT PENYAKIT DAHULU
1. Pernah mengalami gangguan jiwa di masa lalu?
 Ya
 Tidak
Jika Ya, jelaskan kapan, tanda / keluahan:
.................................................................................................................................

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

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

2. Faktor penyebab/pendukung:
a. Riwayat trauma

Usia Pelaku Korban Saksi


1. Aniaya fisik ................ ................ ................ ................

2. Aniaya seksual ................ ................ ................ ................

3. Penolakan ................ ................ ................ ................

4. Kekerasan dalam keluarga ................ ................ ................ ................

5. Tindakan kriminal ................ ................ ................ ................

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

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

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

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

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

Diagnosa Keperawatan:
b. Pernah melakukan upaya/percobaan/bunuh diri
Jelaskan:
.................................................................................................................................

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

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

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

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

Diagnosa Keperawatan:

c. Pengalaman masa lalu yang tidak menyenangkan (peristiwa kegagalan, kematian,


perpisahan)
Jika ada jelaskan
.................................................................................................................................
.................................................................................................................................

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

Diagnosa Keperawatan:
d. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
 Ya
 Tidak
Jika Ya jelaskan
.................................................................................................................................

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

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

Diagnosa Keperawatan:
e. Riwayat penggunaan NAPZA
.................................................................................................................................

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

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

Diagnosa Keperawatan:
3. Upaya yang telah dilakuakna terkait kondisi di atas dan hasilnya:
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:
4. Riwayat penyakit keluarga
Anggota keluarga yang gangguan jiwa?
 Ada
 Tidak
Jika ada:
Hubungan keluarga:
.................................................................................................................................

Gejala:

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

Riwayat pengobatan:

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

Diagnosa Keperawatan:
V. PENGKAJIAN PSIKOSOSIAL (sebelum dan sesudah sakit)
1. Genogram:

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

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

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

Diagnosa Keperawatan:
2. Konsep diri
a. Citra tubuh
.................................................................................................................................

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

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

b. Identitas
.................................................................................................................................

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

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

c. Peran
.................................................................................................................................

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

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

d. Ideal diri
.................................................................................................................................

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

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

e. Harga diri
.................................................................................................................................

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

3. Hubungan sosial
a. Orang yang berarti/terdekat
.................................................................................................................................

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

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

b. Peran serta dalam kegiatan kelompok/masyarakat dan hubungan sosial


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

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

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

c. Hambatan dalam berhubungan dengan orang lain


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

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

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

Diagnosa Keperawatan:

4. Spiritual
a. Nilai dan keyakinan
.................................................................................................................................

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

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

b. Kegiatan ibadah
.................................................................................................................................

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

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

Diagnosa Keperawatan:
VI. PEMERIKSAAN FISIK
1. Keadaan umum
.................................................................................................................................

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

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

2. Kesadaran (kuantitas)
.................................................................................................................................

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

3. Tanda vital:
TD : ........... mmHg, N : ........... x/menit, S : ...........OC, P = ........... x/menit
4. Antopometri
BB = ........... Kg, TB = ........... Cm
5. Keluhan fisik:
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:
VII. STATUS MENTAL
1. Penampilan (penampilan usia, cara berpakaian, kebersihan)
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:
2. Pembicaraan (frekuensi, volume, jumlah, karakter)
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:
3. Aktifitas motorik/psikomotor
Kelambatan:
 Hipokinesia, hipoaktifitas
 Katalepsi
 Sub stupor katatonik
 Fleksibilitas serea
Jelaskan:
.................................................................................................................................

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

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

Peningkatan:
 Hiperkinesia, hiperaktifitas  Grimace
 Stereotipe  Otomatisma
 Gaduh Gelisah katatonik  Negativisme
 Mannarism  Reaksi konversi
 Katapleksi  Tremor
 Tik  Verbigerasi
 Ekhopraxia  Berjalan kaku/rigid
 Command automatism  Kompulsif: sebutkan.................
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:
4. Mood dan Afek
a. Mood
 Depresi  Khawatir
 Ketakutan  Anhedonia
 Euforia  Kesepian
 Lain-lain
Jelaskan:
.................................................................................................................................

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

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

b. Afek
 Sesuai  Tidak sesuai
 Tumpul/dangkal/datar  Labil
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:
5. Interaksi selama wawancara
 Bermusuhan  Kontak mata kurang
 Tidak Kooperatif  Defensif
 Mudah tersinggung  Curiga
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:
6. Persepsi sensorik
a. Halusinasi
 Pendengaran
 Penglihatan
 Perabaan
 Pengecapan
 Peciuman
b. Ilusi
 Ada
 Tidak
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:
7. Proses pikir
a. Arus pikir
 Koheren  Inkoheren
 Sirkumstansial  Asosiasi longgar
 Tangensial  Flight of idea
 Blocking  Perseverasi
 Logorhoe  Neologisme
 Clang Assosiation  Main kata-kata
 Afasia  Lain-lain.......
Jelaskan:
.................................................................................................................................

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

b. Isi pikir
 Obsesif  Fobia, Sebutkan............
 Ekstasi  Waham:
 Fantasi  Agama
 Alienasi  Somatik/hipokondria
 Pikiran Bunuh diri  Kebesaran
 Preokupasi  Kejar/Curiga
 Pikiran isolasi  Nihilistik
 Ide yang terkait  Dosa
 Pikiran rendah diri  Sisip pikir
 Pesimisme  Siar pikir
 Pikiran magis  Kontrol pikir
 Pikiran curiga  Lain-lain ................
Jelaskan:
.................................................................................................................................

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

c. Bentuk pikir
 Realistik
 Non Realistik
 Dereistik
 Otistik
Jelaskan:
.................................................................................................................................

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8. Kesadaran
 Orientasi (Waktu, tempat, orang)
Jelaskan:
.................................................................................................................................

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

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

 Meninggi
 Menurun:
 Kesadaran Berubah
 Hipnosa

 Confusion

 Sedasi

 Stupor

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

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

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

Diagnosa Keperawatan:
9. Memori
 Gangguan daya ingat jangka panjang (>1 bulan)
 Gangguan daya ingat jangka menengah (24 jam - ≤ 1 bulan)
 Gangguan daya ingat jangka pendek (10 detik – 15 menit)
Jelaskan:
.................................................................................................................................

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

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Diagnosa Keperawatan:
10. Tingkat konsentrasi dan berhitung
a. Konsentrasi
 Mudah beralih
 Tidak mampu berkonsentrasi
Jelaskan
.................................................................................................................................

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

b. Berhitung
Jelaskan:
.................................................................................................................................

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

Diagnosa Keperawatan:

11. Kemampuan penilaian


 Gangguan ringan
 Gangguan bermakna
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:

12. Daya tilik diri


 Mengingkari penyakit yang diderita
 Menyalahkan hal-hal yang di luar dirinya
Jelaskan:
.................................................................................................................................

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

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

Diagnosa Keperawatan:
VIII. KEBUTUHAN PERSIAPAN PASIEN PULANG
1. Kemampuan klien memenuhi kebutuhan
 Perawatan kesehatan
 Transportasi
 Tempat tinggal
 Keuangan dan kebutuhan lainnya
Jelaskan:
.................................................................................................................................

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

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

2. Kegiatan hidup sehari-hari


a. Perawatn diri
1) Mandi
Jelaskan:
............................................................................................................................

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

2) Berpakaian, berhias dan berdandan


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

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

3) Makan
Jelaskan:
..............................................................................................................................

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

4) Toiletting (BAK,BAB)
Jelaskan:
..............................................................................................................................

..............................................................................................................................
Diagnosa Keperawatan:
b. Nutrisi
Berapa frekuensi makan dan frekuensi kudapan dalam sehari
..............................................................................................................................

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

Bagaimana nafsu makannya


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

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

Bagaimana berat badannya


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

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

Diagnosa Keperawatan:
c. Tidur
1) Istirahat dan tidur
Tidur siang, lama : ...............s/d...............
Tidur malam, lama ...............s/d...............
Aktifitas sebelum/sesudah tidur: ............... , ...............
Jelaskan:
..............................................................................................................................

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

2) Gangguan tidur
 Insomnia
 Hipersomnia
 Parasomnia
 Lain-lain
Jelaskan
..............................................................................................................................

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

Diagnosa Keperawatan:
3. Kemampuan lain-lain
 Mengantisipasi kebutuhan hidup
..............................................................................................................................

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

 Membuat keputusan berdasarkan keinginannya


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

 Mengatur penggunaan obat dan melakukan pemeriksaan kesehatannya sendiri


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

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

Diagnosa Keperawatan:
4. Sistem pendudukung
Ya Tidak
Keluarga  
Terapis  
Teman sejawat  
Kelompok sosial  
Jelaskan:
..............................................................................................................................

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

Diagnosa Keperawatan
IX. MEKANISME KOPING
Jelaskan:
..............................................................................................................................

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

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

Diagnosa Keperawatan
X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
 Masalah dengan dukungan kelompok, spesifiknya
Jelaskan:
..............................................................................................................................

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

 Masalah berhubungan dengan lingkungan, spesifiknya


Jelaskan,
..............................................................................................................................

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

 Masalah dengan pendidikan, spesifiknya


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

..............................................................................................................................
 Masalah dengan Pekerjaannya, spesifiknya
Jelaskan:
..............................................................................................................................

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

 Masalah dengan perumahan, spesifiknya


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

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

 Masalah dengan ekonomi, spesifiknya


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

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

 Masalah dengan pelayanan kesehatan, spesifiknya


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

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

 Masalah lainnya, spesifiknya


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

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

Diagnosa Keperawatan
XI. ASPEK PENGETAHUAN
Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang
tentang suatun hal
Bagaimana pengetahuan klien/keluarga saat ini tentang penyakit/gangguan jiwa,
perawatan dan penatalaksanaanya faktor yang memperberat masalah (presipitas), obat –
obatan lainnya. Apakah perlu diberikan tambahan pengetahuan yang berkaitan dengan
spesifiknya masalah tsb.
 Penyakit / gangguan jiwa  Penatalaksanaan
 Sistem pendukung  Lain-lain, jelaskan
 Faktor presipitasi
Jelaskan:
..............................................................................................................................

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

Diagnosa Keperawatan:
XII. ASPEK MEDIS
1. Diagnosis medis:
..............................................................................................................................

2. Diagnosis multi axis


Axis I : .....................................................................................................................
Axis II : .....................................................................................................................
Axis III : .....................................................................................................................
Axis IV : .....................................................................................................................

3. Terapi medis
.....................................................................................................................
.....................................................................................................................