36

PENGKAJIAN KEPERAWATAN
KESEHATAN JIWA

Tanggal MRS : ………………..

Tanggal Dirawat di Ruangan : ………………..
Tanggal Pengkajian : ……………........
Ruang Rawat : …………………

I. IDENTITAS KLIEN
Nama : …………………….. (L/P)
Umur : …………….. ………
Alamat : ………………………
Pendidikan : .....................................
Agama : ....................................
Status : ....................................
Pekerjaan : ………………………
JenisKel. : ………………………
No CM : ………………………

II. ALASAN MASUK

a. Data Primer
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b. Data Sekunder
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c. Keluhan Utama Saat Pengkajian
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III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)

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IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)

1. Pernah mengalami gangguan jiwa di masa lalu?
 Ya
 Tidak
JikaYa, Jelaskan kapan, tanda gejala/keluhan :
.........................................................................................................................................
.........................................................................................................................................
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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:
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DiagnosaKeperawatan :
b. Pernah melakukan upaya / percobaan / bunuh diri
Jelaskan:
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Diagnosa Keperawatan :

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

perpisahan )
Jika ada jelaskan :
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Diagnosa Keperawatan :
d. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
 Ya
 Tidak
Jika ya Jelaskan
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Diagnosa Keperawatan :
e. Riwayat Penggunaan NAPZA
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Diagnosa Keperawatan :
3. Upaya yang telah dilakukan terkait kondisi di atas dan hasilnya :
Jelaskan:
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........................................................................................................................................
........................................................................................................................................
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:
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Jelaskan:
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Diagnosa Keperawatan :
2. 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. Hargadiri:
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Diagnosa Keperawatan :
3. Hubungan Sosial
a. Orang yang berarti/terdekat
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b. Peran serta dalam kegiatan kelompok/masyarakat dan hubungan sosial
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c. Hambatan dalam berhubungan dengan orang lain
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Diagnosa Keperawatan :
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4. Spiritual
a. Agama
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b. Pandangan terhadap gangguan jiwa
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Diagnosa Keperawatan:

VI. PEMERIKSAAAN FISIK

1. Keadaan umum
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2. Kesadaran (Kuantitas)
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3. Tanda vital:
TD : ……. mm/Hg
N :…….. x/menit
S : …….. CO
P : …….. x/menit
4. Ukur:
BB : ……. Kg
TB : ……. Cm
5. Keluhan fisik:
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Jelaskan :
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Diagnosa Keperawatan :
VII.STATUS MENTAL
1. Penampilan (Penanpilan usia, cara perpakaian, kebersihan)
Jelaskan:
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Diagnosa Keperawatan:
2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter) :
Jelaskan:
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Diagnosa Keperawatan:

3. Aktifitas motorik/Psikomotor
Kelambatan :
 Hipokinesia,hipoaktifitas
 Katalepsi
 Sub stupor katatonik
 Fleksibilitas serea
Jelaskan:
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Peningkatan :
 Hiperkinesia, hiperaktifitas  Grimace
 Stereotipi  Otomatisma
 Gaduh Gelisah Katatonik  Negativisme
 Mannarism  Reaksikonversi
 Katapleksi  Tremor
 Tik  Verbigerasi
 Ekhopraxia  Berjalankaku/rigid
 Command automatism  Kompulsif :sebutkan …………

Jelaskan:
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DiagnosaKeperawatan:
4. Mood dan Afek
a. Mood
 Depresi  Khawatir
 Ketakutan  Anhedonia
 Euforia  Kesepian
 Lain lain
Jelaskan
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b. Afek
 Sesuai  Tidaksesuai
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 Tumpul/dangkal/datar  Labil
Jelaskan:
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DiagnosaKeperawatan

5. Interaksi Selama Wawancara

 Bermusuhan  Kontak mata kurang
 Tidak kooperatif  Defensif
 Mudah tersinggung  Curiga
Jelaskan:
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Diagnosa Keperawatan
6. Persepsi Sensorik
a. Halusinasi
 Pendengaran
 Penglihatan
 Perabaan
 Pengecapan
 Penciuman
b. Ilusi
 Ada
 Tidakada
Jelaskan:
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Diagnosa Keperawatan
7. Proses Pikir
a. Arus Pikir:
 Koheren  Inkoheren
 Sirkumtansial  Asosiasi longgar
 tangensial  Flight of Idea
 Blocking  Perseverasi
 Logorhoe  Neologisme
 Clang Association  Main kata kata
 Afasia  Lain lain…
Jelaskan:
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b. Isi Pikir
 Obsesif  Fobia, sebutkan…………..
 Ekstasi  Waham:
 Fantasi o Agama
 Alienasi o Somatik/hipokondria
 Pikiranbunuhdiri o Kebesaran
 Preokupasi o Kejar / curiga
 Pikiran isolasi sosial o Nihilistik
 Ide yang terkait o Dosa
 Pikiran Rendah diri o Sisip pikir
 Pesimisme o Siar piker
 Pikiran magis o Kontrol pikir
 Pikiran curiga  Lain lain :
Jelaskan:
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c. Bentuk pikir :
 Realistik
 Non realistik
 Dereistik
 Otistik
Jelaskan:
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Diagnosa Keperawatan:

8. Kesadaran
 Orientasi (waktu, tempat, orang)
Jelaskan:
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 Meninggi
 Menurun:
 Kesadaran berubah
 Hipnosa
 Confusion
 Sedasi
 Stupor
Jelaskan:
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Diagnosa Keperawatan:
9. Memori
 Gangguan daya ingat jangka panjang ( > 1 bulan)
 Gangguan daya ingat jangka menengah ( 24 jam - ≤ 1 bulan)
 Gangguan daya ingat pendek (kurun waktu 10 detik sampai 15 menit)
Jelaskan:
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Diagnosa Keperawatan:
10. Tingkat Konsentrasi dan Berhitung
a. Konsentrasi
 Mudah beralih
 Tida kmampu berkonsentrasi
Jelaskan:
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b. Berhitung
Jelaskan:
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Diagnosa Keperawatan:
11. KemampuanPenilaian
 Gangguan ringan
 Gangguan bermakna
Jelaskan :
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Diagnosa Keperawatan:
12. DayaTilikDiri
 Mengingkari penyakit yang diderita
 Menyalahkan hal-hal diluar dirinya
Jelaskan:
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Diagnosa Keperawatan:

VIII. KEBUTUHAN PERSIAPAN PULANG

1. Kemampuan klien memenuhi kebutuhan
 Perawatan kesehatan,

 transportasi,
 tempat tinggal.
 Keuangan dan kebutuhan lainnya.
Jelaskan:
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2. Kegiatan Hidup Sehari hari
a. Perawatan diri
1) Mandi
Jelaskan :
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2) Berpakaian, berhias dan berdandan

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Jelaskan :
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3) Makan
Jelaskan :
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4) Toileting (BAK, BAB)
Jelaskan :
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Diagnosa Keperawatan:
b. Nutrisi
Berapa frekwensi makan dan frekwensi kudapan dalam sehari.
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Bagaimana nafsu makannya
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Bagaimana berat badannya.
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Diagnosa Keperawatan:
c. Tidur
1) Istirahat dan tidur
Tidur siang, lama : ____________ s/d _____________
Tidur malam, lama : _____________ s/d _____________
Aktifitas sebelum/sesudah tidur : __________ , _________
Jelaskan
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2) Gangguan tidur
 Insomnia
 Hipersomnia
 Parasomnia
 Lain lain
Jelaskan
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Diagnosa Keperawatan:

3. Kemampuan lain lain

 Mengantisipasi kebutuhan hidup

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 Membuat keputusan berdasarkan keinginannya,
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 Mengatur penggunaan obat dan melakukan pemeriksaan kesehatannya sendiri.
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Diagnosa Keperawatan:
4. Sistem Pendukung Ya Tidak
Keluarga 
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
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Diagnosa Keperawatan:

IX. MEKANISME KOPING

Jelaskan :
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Diagnosa Keperawatan:

X. MASALAH PSIKOSOSIALDAN LINGKUNGAN

 Masalah dengan dukungan kelompok, spesifiknya
Jelaskan :
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 Masalah berhubungan dengan lingkungan, spesifiknya
Jelaskan :
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 Masalah dengan pendidikan, spesifiknya
Jelaskan :
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 Masalah dengan pekerjaan, spesifiknya
Jelaskan :
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 Masalah dengan perumahan, spesifiknya
Jelaskan :
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 Masalah dengan ekonomi, spesifiknya
Jelaskan :
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 Masalah dengan pelayanan kesehatan, spesifiknya
Jelaskan :
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 Masalah lainnya, spesifiknya
Jelaskan :
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Diagnosa Keperawatan:
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XI. ASPEK PENGETAHUAN

Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang
tentang suatu hal?
Bagaimana pengetahuan klien/keluarga saat ini tentang penyakit/gangguan jiwa,
perawatan dan penatalaksanaanya faktor yang memperberat masalah (presipitasi), obat-
obatan atau lainnya. Apakah perlu diberikan tambahan pengetahuan yang berkaitan
dengan spesifiknya masalah tsb.
 Penyakit/gangguan jiwa  Penatalaksanaan
 Sistem pendukung  Lain-lain, jelaskan
 Faktor presipitasi
Jelaskan :
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Diagnosa Keperawatan:
XII. ASPEK MEDIS
1. Diagnosis Medis :
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2. Diagnosa Multi Axis

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

3. Terapi Medis
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XIII. ANALISA DATA

DIAGNOSA
NO DATA
KEPERAWATAN
1. DS:
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DO:
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2. DS:
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DO:
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3. DS:
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DO:
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4. DS:
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DO:
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dst DS:
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DO:
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XIV. DAFTAR DIAGNOSA KEPERAWATAN

1. ………………………………………
2. ………………………………………
3. ………………………………………
4. ………………………………………
5. ………………………………………
6. ………………………………………
7. ………………………………………
8. dst

XV. POHON MASALAH

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XVI. PRIORITAS DIAGNOSA KEPERAWATAN

1. ……………………………………………….
2. ………………………………………………
3. ………………………………………………
4. .………………………………………………

Lawang, ……………………….
Mahasiswa yang mengkaji

____________________
NIM................................
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TINDAKAN KEPERAWATAN JIWA

Nama :
No CM :
No Tindakan Keperawatan Evaluasi
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Keterangan :
Cara pendokumentasian :
 Pada kolom Tindakan Keperawatan diisi :
 Tanggal & jam tindakan
 Data (Tanda gejala dan kemampuan)
 Diagnosa Keperawatan
 Tindakan Keperawatan
 Kolom Evaluasi:
 Evaluasi subyektif & Obyektif
 Berdasarka nrespon subyektif, evaluasi obyektif
 Sesuai hasil evaluasi respon subyektif & obyektif pada fase terminasi
 A : Analisa Sesuai kemampuan Pasien
 P : Planning , terdiri dari P pasien dan P perawat
 P pasien : berdasarkan hasil rencana tindak lanjut pada fase terminasi
 P perawat : berdasarkan hasil kontrak yang akan datang pada fase
terminasi