PROGRAM STUDI PROFESI NERS

INSTITUT TEKNOLOGI DAN KESEHATAN BALI

PENGKAJIAN KEPERAWATAN
KESEHATAN JIWA

RUANG RAWAT: TANGGAL DIRAWAT:

I. IDENTITAS KLIEN
Inisial :___________________________ (L/P) Tanggal Pengkajian: :_____________________
Umur :___________________________ RM No. :_____________________
Alamat :___________________________
Pekerjaan :___________________________
Informan :___________________________

II. ALASAN MASUK

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III. FAKTOR PRESIPITASI/ RIWAYAT PENYAKIT SEKARANG

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IV. FAKTOR PREDISPOSISI
 RIWAYAT PENYAKIT LALU
1. Pernah mengalami gangguan jiwa di masa lalu? ya tidak

Bila ya jelaskan
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2. Pengobatan sebelumnya Berhasil Kurang Berhasil Tidak Berhasil

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

Bila ya jelaskan
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 RIWAYAT PSIKOSOSIAL
Pelaku/ usia Korban/ usia Saksi/ usia
1. Aniaya fisik
2. Aniaya seksual
3. Penolakan
4. Kekerasan dalam keluarga
5. Tindakan kriminal

Jelaskan :___________________________________________________________________
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6. Pengalaman masa lalu lain yang tidak menyenangkan (bio, psiko, sosio, kultural, spiritual):
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Masalah keperawatan :
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7. Kesan Kepribadian klien: extrovert introvert lain-lain :__________________

 RIWAYAT PENYAKIT KELUARGA

1. Adakah anggota keluarga yang mengalami gangguan jiwa?

ya tidak
Hubungan keluarga Gejala Riwayat Pengobatan/ perawatan
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 Masalah keperawatan :
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V. STATUS MENTAL

1. Penampilan
tidak rapi penggunaan pakaian Cara berpakaian
tidak sesuai tidak seperti biasanya

Jelaskan : _______________________________________________________________________
Masalah keperawatan : ____________________________________________________________

2. Kesadaran
 Kwantitatif/ penurunan kesadaran]
compos mentis apatis/ sedasi somnolensia
sopor subkoma koma

 Kwalitatif
tidak berubah berubah
meninggi gangguan tidur: sebutkan______________________________
hipnosa disosiasi: sebutkan____________________________________

3. Disorientasi
waktu tempat orang

Jelaskan:
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Masalah keperawatan : ____________________________________________________________

4. Aktivitas Motorik/ Psikomotor

Kelambatan:
hipokinesia, hipoaktivitas sub stupor katatonik
katalepsi flexibilitas serea

Peningkatan:
hiperkinesia, hiperaktivitas gaduh gelisah katatonik
TIK grimase
tremor gagap
stereotipi mannarism
katalepsi akhopraxia
command automatism atomatisma
nagativisme reaksi konversi
verbigerasi berjalan kaku/ rigit
kompulsif lain-2 sebutkan

5. Afek/ Emosi
adequat tumpul dangkal/ datar
labil inadequat anhedonia
marasa kesepian eforia ambivalen apati
marah depresif/ sedih
cemas: ringan sedang
berat panik

Jelaskan :__________________________________________________________________
Masalah keperawatan :
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6. Persepsi
halusinasi ilusi depersonalisasi
derealisasi

Macam Halusinasi
pendengaran penglihatan perabaan
pengecapan penghidu/ pembauan lain-lain, sebutkan...................

Jelaskan :_________________________________________________________________
Masalah keperawatan :
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7. Proses Pikir
 Arus Pikir
koheren inkoheren asosiasi longgar
fligt of ideas blocking pengulangan pembicaraan/
persevarasi
tangansial sirkumstansiality logorea
neologisme bicara lambat bicara cepat
irelevansi main kata-kata afasi
assosiasi bunyi lain2 sebutkan..

Jelaskan :_________________________________________________________________
Masalah keperawatan :
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 Isi Pikir
obsesif ekstasi fantasi
bunuh diri ideas of reference pikiran magis
alienasi isolaso sosial rendah diri
preokupasi pesimisme fobia sebutkan.........................
waham: sebutkan jenisnya
agama somatik, hipokondrik kebesaran
curiga nihilistik sisip pikir
siar pikir kontrol pikir kejaran
dosa

Jelaskan :__________________________________________________________________
Masalah keperawatan :
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 Bentuk Pikir
realistik nonrealistik
autistik dereistik

8. Memori
gangguan daya ingat jangka panjang gangguan daya ingat jangka pendek
gangguan daya ingat saat ini amnesia, sebutkan.........................
paramnesia, sebutkan jenisnya........................................................
hipermnesia, sebutkan ...................................................................

Jelaskan :_________________________________________________________________
Masalah keperawatan :
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 9. Tingkat Konsentrasi dan Berhitung
mudah beralih tidak mampu berkonsentrasi tidak mampu berhitung
sederhana

Jelaskan :_________________________________________________________________
Masalah keperawatan :
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10. Kemampuan Penilaian

gangguan ringan gangguan bermakna

Jelaskan :__________________________________________________________________
Masalah keperawatan :
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11. Daya Tilik Diri/ Insight

mengingkari penyakit yang diderita menyalahkan hal-hal diluar dirinya

Jelaskan :__________________________________________________________________
Masalah keperawatan :
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12. Interaksi selama Wawancara

bermusuhan tidak kooperatif mudah tersinggung
kontak mata kurang defensif curiga

Jelaskan :_________________________________________________________________
Masalah keperawatan :
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VI. FISIK
1. Keadaan umum ____________________________________________________________________
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2. Tanda vital: TD:___________N:___________ S:_____________ P:_______

3. UKur: TB:___________ BB:__________ turun naik
4. Keluhan fisik: tidak ya jelaskan...............................
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5. Pemeriksaan fisik:
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Jelaskan
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Masalah keperawatan :
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VII. PENGKAJIAN PSIKOSOSIAL (sebelum dan sesudah sakit)

1. 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. Harga diri :___________________________________________________________________
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Masalah keperawatan : _________________________________________________________________

2. Genogram
 3. Hubungan Sosial
a. Hubungan terdekat :

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b. Peran serta dalam kelompok/ masyarakat

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c. Hambatan dalam berhubungan dengan orang lain
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Masalah keperawatan :
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4. Spiritual dan kultural

a. Nilai dan keyakinan
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b. Konflik nilai/ keyakinan/ budaya
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c. Kegiatan ibadah
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Masalah keperawatan:
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VIII. AKTIVITAS SEHARI-HARI (ADL)

1. Makan
Bantuan minimal Sebagian Bantuan total

2. BAB/BAK
Bantuan minimal Sebagian Bantuan total

3. Mandi
Bantuan minimal Sebagian Bantuan total

4. Berpakaian/berhias
Bantuan minimal Sebagian Bantuan total

5. Istirahat dan tidur

Tidur siang lama : ______________________ s/d
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Tidur malam lama : ______________________ s/d
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Aktivitas sebelum / sedudah tidur : _____________________ s/d
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6. Penggunaan obat
Bantuan minimal Sebagian Bantuan total

7. Pemeliharaan kesehatan
Perawatan Lanjutan Ya Tidak
Sistem pendukung Ya Tidak

8. Aktivitas di dalam rumah

Mempersiapkan makanan Ya Tidak
 Menjaga kerapihan rumah Ya Tidak

Mencuci pakaian Ya Tidak

Pengaturan keuangan Ya Tidak

9. Aktivitas di luar rumah

Belanja Ya Tidak
Transportasi Ya Tidak
Lain-lain Ya Tidak

Jelaskan :__________________________________________________________________

Masalah keperawatan : ____________________________________________________________

IX. MEKANISME KOPING

Adatif Maladaptif
Bicara dengan orang lain Minum Alkohol
Mampu menyelesaikan masalah Reaksi lambat / berlebih
Teknik relokasi Bekerja berlebihan
Aktivitas konstruktif Menghindar
Olah raga Mencederai diri
Lainnya ...................... Lainnya ......................
Masalah keperawatan : ______________________________________________________________

X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Masalah dengan dukungan kelompok, uraikan
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Masalah berhubungan dengan lingkungan, uraikan
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Masalah dengan pendidikan, uraikan
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Masalah dengan pekerjaan, uraikan
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Masalah dengan perumahan, uraikan
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Masalah dengan ekonomi, uraikan
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Masalah dengan pelayanan kesehatan, uraikan
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Masalah lainnya, uraikan
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Masalah keperawatan : ______________________________________________________________
XI. KURANG PENGETAHUAN TENTANG
Penyakit jiwa Sistem pendukung
Faktor presiptasi Penyakit fisik
Koping Obat-obatan
Lainnya _______________________________________________________________________
Masalah keperawatan : ______________________________________________________________

XII. ASPEK MEDIK

Diagnosa medik : _________________________________________________________________

Terapi medik : _________________________________________________________________

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XIII. DAFTAR MASALAH KEPERAWATAN

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XIV. ANALISA DATA

No DATA MASALAH
XV. POHON MASALAH

XVI. DIAGNOSA KEPERAWATAN

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Mahasiswa

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 PROGRAM STUDI S1 KEPERAWATAN
INSTITUT TEKNOLOGI DAN KESEHATAN BALI

DAFTAR DIAGNOSA KEPERAWATAN

(Berdasarkan Core Problem)
Ruang :
Nama Pasien :
No. Register :
No. TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TANDA
Dx MUNCUL TERATASI TANGAN
 PROGRAM STUDI S1 KEPERAWATAN
INSTITUT TEKNOLOGI DAN KESEHATAN BALI

IMPLEMENTASI DAN EVALUASI

KEPERAWATAN KESEHATAN JIWA

Nama : ___________________ Ruangan : _________________ RM No. : ____________________

No. Tanggal & DIAGNOSA KEPERAWATAN EVALUASI

Dx Jam
 PROGRAM STUDI S1 KEPERAWATAN
INSTITUT TEKNOLOGI DAN KESEHATAN BALI

LAPORAN PENDAHULUAN
STRATEGI PELAKSANAAN
TINDAKAN KEPERAWATAN HARI KE..................

A. PROSES KEPERAWATAN
1. Kondisi klien:
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2. Diagnosa keperawatan:
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3. Tujuan khusus:
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4. Tindakan keperawatan:
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B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN

KEPERAWATAN
ORIENTASI
1. Salam Terapeutik:
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2. Evaluasi/ Validasi:
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3. Kontrak: Topik, waktu, dan tempat
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KERJA: Langkah-Langkah Tindakan keperawatan

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TERMINASI:
1. Evaluasi respon klien terhadap tindakan keperawatan:
Subyektif:
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 Obyektif:
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2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang
telah dilakukan):
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3. Kontrak yang akan datang (Topik, waktu, dan tempat):

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