PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

RUANGAN RAWAT :…………………TANGGAL DIRAWAT:………………..

I. IDENTITAS KLIEN
Inisial : (L/P) Umur : Tahun No.RM :
II. ALASAN MASUK
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III.FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu ?
Ya
Tidak
2. Pengobatan sebelumnya.
Berhasil
Kurang berhasil
Tidak berhasil
3. Trauma Usia Pelaku Korban Saksi
Aniaya fisik
Aniaya seksual
Penolakan
Kekerasan dalam keluarga

Tindakan kriminal

Jelaskan : ...................................................................................................
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Masalah Keperawatan :. . …………………………………………………

4. Adakah anggota keluarga yang mengalami gangguan jiwa ?
Ya
Tidak
Hubungan keluarga :…………………………………………………..
Gejala :…………………………………………………...
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Riwayat pengobatan :…………………………………………………...
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Masalah Keperawatan :…………………………………………………..
5. Pengalaman masa lalu yang tidak menyenangkan
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Masalah Keperawatan : …………………………………………………….
IV. PEMERIKSAAN FISIK
1. Tanda-tanda vital : TD : .........mmHg N : ........x/i
S : .........C P : ........x/i
2. Ukur : TB : .........Kg BB : ........cm
3 Keluhan fisik :......................................................................................
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Masalah keperawata :......................................................................................
V. PSIKOSOSIAL
1. Genogram :
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2. Konsep diri
a. Gambaran diri
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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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3. Hubungan Sosial
a. Orang yang berarti :
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b. Peran serta dalam kegiatan kelompok / masyarakat :
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c.Hambatan dalam berbuhungan dengan orang Lain :
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Masalah keperawatan:..................................................................................

4. Spiritual
a. Nilai dan keyakinan :
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b. Kegiatan ibadah :
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Masalah Keperawatan : ................................................................................
VI. STATUS MENTAL
1. Penampilan
Tidak rapi
Penggunaan pakaian tidak sesuai
Cara berpakaian tidak seperti biasanya
Jelaskan :
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Masalah Keperawatan : ..............................................................................
2. Pembicaraan
Cepat
Keras
Gagap
Inkoheren
Lambat
Membisu
Tidak mampu memulai pembicaraan
Jelaskan :
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Masalah Keperawatan : ..............................................................................
3. Aktivitas Motorik:
Lesu
Tegang
Gelisah
Agitasi
Tik
Grimasen
 Tremor
Kompulsif
Jelaskan :
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Masalah Keperawatan : ..............................................................................
4. Alam perasaaan
Sedih
Ketakutan
Putus asa
Khawatir
Gembira berlebihan
Jelaskan : .......................................................................
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Masalah Keperawatan : ..............................................................................
5. Afek
Datar
Tumpul
Labil
Tidak sesuai
Jelaskan : .......................................................................
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Masalah Keperawatan : ..............................................................................
6. lnteraksi selama wawancara
Bermusuhan
Tidak kooperatif
Mudah tersinggung
Kontak mata kurang
Defensif
Curiga
Jelaskan :
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Masalah Keperawatan : ...............................................................................
7. Persepsi
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penghidu/Pengciuman
Jelaskan :
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Masalah Keperawatan : ...............................................................................
8. Isi Pikir
Obsesi
Fobia
Hipokondria
Depersonalisasi
Ide yang terkait
Pikiran magis
 Waham :
Agama
Somatik
Kebesaran
Curiga
Nihilistic
Sisip pikir
Siar pikir
Kontrol pikir
Jelaskan :
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Masalah Keperawatan : ..............................................................................
9. Arus pikir
Sirkumstansial
Tangensial
Kehilangan asosiasi
Flight of idea
Blocking
Pengulangan pembicaraan/perseverasi
Jelaskan :
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Masalah Keperawatan : ..............................................................................
10. Tingkat kesadaran
Bingung
Sedasi
Stupor
Disorientasi
 Waktu
Tempat
Orang
Jelaskan :
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Masalah Keperawatan : ..............................................................................
11. Memori
Gangguan daya ingat jangka panjang
Gangguan daya ingat jangka pendek
Gangguan daya ingat saat ini
Konfabulasi
Jelaskan :
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Masalah Keperawatan : ................................................................................
12. Tingkat konsentrasi dan berhitung
Mudah beralih
Tidak mampu konsentrasi
Tidak mampu berhitung sederhana
Jelaskan :
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Masalah Keperawatan : ................................................................................
 13. Kemampuan penilaian
Gangguan ringan
Gangguan bermakna

Jelaskan :
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Masalah Keperawatan : .............................................................................
14. Daya tilik diri
Mengingkari penyakit yang diderita
Menyalahkan hal-hal diluar dirinya
VII. Kebutuhan Persiapan Pulang
1. kemampuan klien memenuhi kebutuhan
Ya Tidak
Makan
Keamanan
Perawatan kesehatan
Pakaian
Transportasi
Tempat tinggal
Uang
Jelaskan :
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Masalah Keperawatan : ................................................................................
2. kegiatan hidup sehari-hari
a. Perawatan diri Bantuan Total Bantuan Minimal
Mandi
Kebersihan
Makan
BAB/ BAK
Ganti pakaian
Jelaskan : .....................................................................................................
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Masalah Keperawatan : ...............................................................................
b. Nutrisi
Apakah anda puas dengan pola makan anda ?
Ya
Tidak
Jelaskan : .....................................................................................................
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Apakah anda memisahkan diri ?
Ya,
Tidak
Jelaskan : .....................................................................................................
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Frekuensi makan sehari :
Frekuensi kudapan sehari :
Nafsu makan :
Meningkat
Menurun
Berlebihan
 Sedikit-sedikit
Berat Badan :
Meningkat
Menurun
BB terendah : kg BB tertinggi : kg
Jelaskan : .....................................................................................................
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Masalah Keperawatan : ..............................................................................
c.Tidur
1) Apakah ada masalah tidur ?
2) Apakah merasa segar setelah bangun tidur ?
3) Apakah ada kebiasaan tidur siang ?
4) Lama tidur siang :
5) Apakah yang menolong tidur ?
Tidur malam jam: , Bangun jam :
Apakah ada gangguan tidur
Sulit untuk tidur
Bangun terlalu pagi
Somnabulisme
Terbangun saat tidur
Berbicara saat tidur

Jelaskan : ................................................................................
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3. Kemampuan klien dalam
Mengantisispasi kebutuhan sendiri
Ya
Tidak
Membuat keputusan berdasarkan kenginan sendiri
Ya
Tidak
Mengantur penggunaan obat
Ya
Tidak
Melakukan pemeriksaan kesehatan
Ya
Tidak

Jelaskan : ............................................................................................
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Klien memiliki sistem pendudukung keluarga
Keluarga : Ya : Tidak :
Terapis Ya : tidak :
Teman sejawat Ya : tidak :
Kelompok sosial Ya : tidak :

Jelaskan : ..............................................................................................
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 Apakah klien menikmati saat bekerja, kegiatan produktif atau Hobi?
Ya
Tidak

Jelaskan : ..............................................................................................
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VIII. Mekanisme Koping
Adaptif Maladaptif
Bicara dengan orang lain Minum alkohol
Mampu menyelesaikan masalah Reaksi lambat/berlebih
Teknik relaksasi Bekerja berlebihan
Aktivitas konstruktif Menghindar
Olahraga Mencederai diri
lainnya : lainnya :
Masalah Keperawatan : ................................................................................
IX. Masalah Psikososial dan Lingkungan:
Masalah dengan dukungan kelompok
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Masalah dengan dukungan Pendidikan
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Masalah dengan dukungan pekerjaan
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Masalah dengan dukungan pekerjaan

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Masalah dengan dukungan perumahan
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Masalah dengan dukungan ekonomi
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Masalah dengan pelayanan kesehatan
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X. Pengetahuan Kurang Tentang:
Penyakit jiwa
Faktor presipitasi
Koping
System pendukung
Penyakit fisik
Obat-obatan
Lainnya :
Masalah Keperawatan :....................................................................................
XI. Aspek Medik
Diagnosa Medik :...............................................................................................
Terapi Medik : .............................................................................................
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