Pengkajian Askep Jiwa

PENGKAJIAN KEPERAWATAN KESEHATAN JIWA
IDENTITAS KLIEN
Nama : ........................................................
Tanggal Dirawat : ........................................................
Umur : ........................................................
Tanggal Pengkajian : ........................................................
Alamat : ........................................................
Pendidikan : ........................................................
Agama : ........................................................
Ruang Rawat : ........................................................
Status : ........................................................
Pekerjaan : ........................................................
Jenis Kelamin : ........................................................
No. RM : ........................................................
ALASAN MASUK
a. Data primer
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b. Data sekunder
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RIWAYAT PENYAKIT SEKARANG dan FAKTOR PRESIPITASI

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FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu ?
- Ya
- Tidak
Jika Ya, jelaskan :
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2. Pengobatan sebelumnya
- Berhasil
- Kurang berhasil
- Tidak berhasil
Jelaskan :
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3. a. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)

- Ya
- Tidak
Jika Ya, Jelaskan :
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b. Pernah ada riwayat NAPZA

- Narkotika
- Penyalahgunaan Psikotropika
- Zat aditif : kafein, nikotin, alcohol
- Dll
c. Riwayat Trauma
Usia Pelaku Korban Saksi

Aniaya fisik
Aniaya seksual
Penolakan
Kekerasan dalam keluarga
Tindakan kriminal
Usaha bunuh diri
Jelaskan :
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Masalah / Diagnosa Keperawatan :
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4. Pengalaman masa lalu yang tidak menyenangkan (peristiwa kegagalan,

kematian, perpisahan)
Bila Ya, Jelaskan :
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RIWAYAT PENYAKIT KELUARGA

1. Anggota keluarga yang gangguan jiwa ?
- Ada
- Tidak
Kalau Ada :
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Hubungan Keluarga :
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Gejala :
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Riwayat Pengobatan :
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PEMERIKSAAN FISIK
Tanggal : ............................................
1. Keadaan umum
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2. Tanda vital
 TD : mm/Hg
 N : x/m
 S : ºC
 P : x/m
3. Ukur : BB: kg, TB : cm
 Turun
 Naik
4. Keluhan fisik
 Nyeri : Ringan (1,2,3), sedang (4,5,6), berat terkontrol (7,8,9), berat tidak
terkontrol (10). (Standar JCI).
Ya :
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S =
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T =
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Tidak
- Keluhan lain :
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- Tidak ada keluhan
Jelaskan :
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PENGKAJIAN PSIKOSOSIAL (Sebelum dan sesudah sakit)
1. Genogram
Keterangan Gambar :
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Jelaskan :
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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1. Hubungan social
a. Orang yang berarti / terdekat :
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b. Peran serta dalam kegiatan kelompok / masyarakat :
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c. Hambatan dalam berhubungan dengan orang lain :
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2. Spiritual
a. Nilai dan keyakinan :
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b. Kegiatan ibadah :
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STATUS MENTAL
1. Penampilan
 Tidak rapi
 Penggunaan pakaian tidak sesuai
 Cara berpakaian tidak sesuai fungsinya
Jelaskan :
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2. Pembicaraan
 Cepat
 Keras
 Gagap
 Apatis
 Lambat
 Membisu
 Tidak mampu memulai pembicaraan
 Lain – lain.............
Jelaskan :
(sesuai data fokus)
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3. Aktifitas motorik / psikomotor kelambatan :

 Hipokinesia, hipoaktifitas
 Katalepsi
 Sub stupor katatonik
 Fleksibilitas serea
Jelaskan :
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Peningkatan :
 Hiperkinesia, hiperaktifitas
 Gagap
 Stereotipi
 Gaduh Gelisah Katatonik
 Mannerism
 Katapleksi
 Tik
 Ekhopraxia
 Command automatism
 Grimace
 Otomatisma
 Negativism
 Reaksi konversi
 Tremor
 Verbigerasi
 Berjalan kaku / rigid
 Kompulsif : sebutkan.............................................................................
jelaskan :
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4. Afek dan Emosi

Pertanyaan :
- Bagaimana perasaan anda akhir akhir ini?
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- Jika tidak ada respon, lanjutkan dengan pertanyaan : bagaimana perasaan anda
senang apa sedih ?
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- Jika pasien tampak sedih, tanyakan : bagaimana sedihnya? Dapatkah anda
menceritakannya?
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- Jika pasien menunjukkan gambaran depresi, lanjutkan dengan pertanyaan :

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- Bagaimana dengan masa depanmu ? apakah anda benar benar tidak punya
harapan ?
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- Jika “ya” Lanjutkan dengan : Bukankah hidup ini berharga?

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- Lanjutkan dengan pertanyaan : adakah keinginan untuk bunuh diri?

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a. Afek
 Adekuat
 Tumpul
 Dangkal / datar
 Inadekuat
 Labil
 Ambivalensi
- Jelaskan :
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- Masalah / Diagnosa Keperawatan :
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b. Emosi
 Merasa Kesepian
 Apatis
 Marah
 Anhedonia
 Eforia
 Cemas (ringan, sedang, berat, panik)
 Sedih
 Depresi
 Keinginan bunuh diri
Jelaskan :
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5. Interaksi selama wawancara

 Bermusuhan
 Tidak kooperatif
 Mudah tersinggung
 Kontak mata kurang
 Defensif
 Curiga
Jelaskan :
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6. Persepsi – sensorik
Pertanyaan pada pasien :
- Apakah anda sering mendengar suara saat tidak ada orang atau saat tidak ada
orang yang berbicara?
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- ATAU : Apakah anda mendengar suara orang yang tidak dapat anda lihat
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- Jika : ‘Ya”
- Apakah itu benar benar suara yang datang dari luar kepala anda atau dalam
pikiran anda ?
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- Apa yang dikatakan oleh suara itu?

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- Berikan contohnya, apa yang anda dengar hari ini atau kemarin!
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Halusinasi
 Pendengaran
 Pengelihatan
 Perabaan
 Pengecapan
 Penciuman
 Kinestetik
 Visceral
 Histerik
 Hipnogogik
 Hipnopompik
 Perintah
 Seksual
Ilusi
 Ada
 Tidak ada
Depersonalisasi
 Ada
 Tidak ada
Derealisasi
 Ada
 Tidak ada
Jelaskan :
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7. Proses Pikir
Pertanyaan :
a. Pernahkan anda percaya bahwa seseorang atau suatu kekuatan diluar anda
memasukkan buah pikiran yang bukan milik anda ke dalam pikiran anda,
atau menyebabkan anda bertindak tidak seperti biasanya?
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b. Pernahkah anda percaya bahwa anda sedang dikirimi pesan khusus melalui
TV, radio atau koran, atau bahwa ada seseorang yang tidak anda kenal secara
pribadi tertarik pada anda?
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c. Pernahkah anda percaya bahwa seseorang sedang membaca pikiran anda

atau bisa mendengar pikiran anda atau bahkan anda bisa membaca atau
mendengar apa yang sedang dipikirkan oleh orang lain?
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d. Pernahkah anda percaya bahwa seseorang sedang memata matai anda, atau
seseorang telah berkomplot melawan anda atau menciderai anda?
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e. Apakah keluarga atau teman anda pernah menganggap keyakinan anda aneh
atau tidak lazim?
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Arus Pikir :
 Koheren
 Inkoheren
 Sirkumtansial
 Neologisme
 Tangensial
 Logorea
 Kehilangan asosiasi
 Bicara lambat
 Flight of idea
 Bicara cepat
 Irrelevansi
 Main kata-kata
 Blocking
 Pengulangan pembicaraan / perseverasi
 Afasia
 Asosiasi bunyi
Jelaskan :
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Isi Pikir
 Obesif
 Ekstasi
 Fantasi
 Aliensi
 Pikiran bunuh diri
 Preokupasi
 Pikiran isolasi sosial
 Ide yang terkait
 Pikiran rendah diri
 Pesimisme
 Pikiran magis
 Pikiran curiga
 Fobia, sebutkan......................................................................................
- Waham :
 Agama
 Somatic/hipokondria
 Kebesaran
 Kejar / curiga
 Nihilistik
 Dosa
 Sipsip pikir
 Siar pikir
 Kontrol pikir
Jelaskan :
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- Gangguan proses pikir :
(jelaskan)
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Lain – lain, jelaskan :

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8. Kesadaran
 Menurun :
 Compos mentis
 Sopor
 Apatis / sedasi
 Subkoma
 Somnolensia
 Koma
 Meninggi
 Hipnosa
 Disosiasi :
 Gangguan perhatian
Jelaskan :
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9. Orientasi
 Waktu
 Tempat
 Orang
Jelaskan :
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10. Memori
 Gangguan daya ingat jangka panjang (>1 bulan)
 Gangguan daya ingat jangka pendek (1 hari – 1 bulan)
 Gangguan daya ingat saat ini (< 24 jam)
 Amnesia
 Paramnesia
 Konfabulasi
 Dejavu
 Jamaisvu
 Fause reconnaissance
 Hiperamnesia
Jelaskan :
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11. Tingkat Konsentrasi dan Berhitung
 Mudah beralih
 Tidak mampu berkonsentrasi
 Tidak mampu berhitung sederhana
Jelaskan :
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12. Kemampuan penilaian

 Gangguan ringan
 Gangguan bermakna
Jelaskan : ( sesuai data fokus)
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Gangguan proses pikir : (jelaskan)

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1. Daya Tilik Diri

 Mengingkari penyakit yang diderita
 Menyalahkan hal-hal diluar dirinya
Jelaskan :
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Gangguan proses pikir : (jelaskan)
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KEBUTUHAN PERSIAPAN PULANG

1. Makan
 Mandiri
 Bantuan minimal
 Bantuan total
Jelaskan :
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2. BAB / BAK
 Mandiri
 Bantuan minimal
 Bantuan total
Jelaskan :
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3. Mandi
 Mandiri
 Bantuan minimal
 Bantuan total
4. Sikat gigi
 Mandiri
 Bantuan minimal
 Bantuan total
5. Keramas
 Mandiri
 Bantuan minimal
 Bantuan total
Jelaskan :
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6. Berpakaian / berhias
 Mandiri
 Bantuan minimal
 Bantuan total
Jelaskan :
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1. Istirahat dan Tidur

- Tidur siang, Lama : s/d
- Tidur malam, Lama : s/d
- Aktifitas sebelum/sesudah tidur :
Jelaskan :
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2. Penggunaan Obat
 Bantuan minimal
 Bantuan total
- Jelaskan :
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- Masalah / Diagnosa Keperawatan :
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9. Pemeliharaan Kesehatan
Ya Tidak
Perawatan Lanjutan
Sistem pendukung Ya Tidak
Keluarga
Terapis
Teman Sejawat
Kelompok Sosial
Jelaskan :
10. Aktifitas dalam Rumah

Ya Tidak
Mempersiapkan makanan
Menjaga kerapihan rumah
Mencuci pakaian
Pengaturan keuangan
11. Aktifitas di luar Rumah

Ya Tidak
Belanja
Transportasi
Lain – lain
Jelaskan :
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MEKANISME KOPING
Adaptif Maladaptif
- Bicara dengan orang lain - Minuman alkohol
- Mampu menyelesaikan masalah - Reaksi lambat / berlebihan
- Teknik relaksasi - Bekerja berlebihan
- Aktifitas konstruktif - Menghindar
- Olah raga - Menciderai diri
- Lain – lain :......... - Lain – lain :
Jelaskan :
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MASALAH PSIKOSOSIAL DAN LINGKUNGAN
- Masalah dengan dukungan kelompok, spesifikasinya

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- Masalah berhubungan dengan lingkungan, spesifikasinya

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- Masalah dengan pendidikan, spesifikasinya
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- Masalah dengan pekerjaan, spesifikasinya

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- Masalah dengan perumahan, spesifikasinya
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- Masalah dengan ekonomi, spesifikasinya

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- Masalah dengan pelayanan kesehatan, spesifikasinya

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- Masalah lainnya, spesifikasinya

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ASPEK PENGETAHUAN
Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang
kurang tentang suatu hal?
 Penyakit/gangguan jiwa
 System pendukung
 Faktor presipitasi
 Mekanisme koping
 Penyakit fisik
 Obat – obatan
 Lain – lain, jelaskan
Jelaskan :
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ASPEK MEDIS
Diagnosis medik :
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Terapi medik :
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ANALISA DATA
NO DATA MASALAH / DIAGNOSA
KEPERAWATAN
DS :
DO :
DS :
DO :
DS :
DO :
DS :
DO :
DAFTAR MASALAH / DIAGNOSA KEPERAWATAN
1. .................................................................................................................................
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5. .................................................................................................................................
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POHON MASALAH
PRIORITAS DIAGNOSA KEPERAWATAN
1. .................................................................................................................................
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Denpasar, .............
Perawat yang mengkaji
NIM / NIRM : ............................

INTERVENSI KEPERAWATAN
KESEHATAN JIWA DI RAWAT INAP RUMAH SAKI JIWA
Inisial Klien :....................

Ruangan :....................
RM No. :....................
Intervensi Keperawatan
Diagnosa Rasional
Tindakan
Tujuan Kriteria Evaluasi
Keperawatan
IMPLEMENTASI DAN EVALUASI KEPERAWATAN KESEHATAN JIWA DI
UNIT RAWAT INAP RUMAH SAKIT JIWA
Nama :............ Ruangan :................ RM

No :............
TANGGAL DX IMPLEMENTASI EVALUASI

KEPERAWATAN
S
O
A
P
Tanda Tangan

Pengkajian Askep Jiwa

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Pengkajian Askep Jiwa

Diunggah oleh

Hak Cipta:

Format Tersedia

PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

RIWAYAT PENYAKIT SEKARANG dan FAKTOR PRESIPITASI

3. a. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)

b. Pernah ada riwayat NAPZA

Usia Pelaku Korban Saksi

4. Pengalaman masa lalu yang tidak menyenangkan (peristiwa kegagalan,

RIWAYAT PENYAKIT KELUARGA

Masalah / Diagnosa Keperawatan :

Masalah / Diagnosa Keperawatan :

Masalah / Diagnosa Keperawatan :

Masalah / Diagnosa Keperawatan :

Masalah / Diagnosa Keperawatan :

3. Aktifitas motorik / psikomotor kelambatan :

4. Afek dan Emosi

- Jika pasien menunjukkan gambaran depresi, lanjutkan dengan pertanyaan :

- Jika “ya” Lanjutkan dengan : Bukankah hidup ini berharga?

- Lanjutkan dengan pertanyaan : adakah keinginan untuk bunuh diri?

5. Interaksi selama wawancara

- Apa yang dikatakan oleh suara itu?

c. Pernahkah anda percaya bahwa seseorang sedang membaca pikiran anda

Lain – lain, jelaskan :

12. Kemampuan penilaian

Gangguan proses pikir : (jelaskan)

1. Daya Tilik Diri

KEBUTUHAN PERSIAPAN PULANG

1. Istirahat dan Tidur

Masalah / Diagnosa Keperawatan :

10. Aktifitas dalam Rumah

11. Aktifitas di luar Rumah

- Masalah dengan dukungan kelompok, spesifikasinya

- Masalah berhubungan dengan lingkungan, spesifikasinya

- Masalah dengan pekerjaan, spesifikasinya

- Masalah dengan ekonomi, spesifikasinya

- Masalah dengan pelayanan kesehatan, spesifikasinya

- Masalah lainnya, spesifikasinya

Masalah / Diagnosa Keperawatan :

NIM / NIRM : ............................

Inisial Klien :....................

Nama :............ Ruangan :................ RM

TANGGAL DX IMPLEMENTASI EVALUASI

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