PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU 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

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

III. FAKTOR PRESIPITASI/ RIWAYAT PENYAKIT SEKARANG

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

Bila ya jelaskan_______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

2. Pengobatan sebelumnya Berhasil Kurang Berhasil Tidak Berhasil

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

ya tidak

Bila ya jelaskan_______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

 RIWAYAT PSIKOSOSIAL
Pelaku/ usia Korban/ usia Saksi/ usia
1. Aniaya fisik
2. Aniaya seksual
3. Penolakan
4. Kekerasan dalam keluarga
5. Tindakan kriminal
Jelaskan :_______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

6. Pengalaman masa lalu lain yang tidak menyenangkan (bio, psiko, sosio, kultural, spiritual):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Masalah keperawatan :________________________________________________________________
____________________________________________________________________________________

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
______________________ ____________________ _______________________________
______________________ ____________________ _______________________________
 Masalah keperawatan
:______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

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:____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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 :
____________________________________________________________________________________
_____________________________________________________________________________________

6. Persepsi
halusinasi ilusi depersonalisasi
derealisasi

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

Jelaskan :_______________________________________________________________________
Masalah keperawatan: __________________________________________________________________
____________________________________________________________________________________

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 :_________________________________________________________________
___________________________________________________________________________________
 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 : _________________________________________________________________
  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 : _________________________________________________________________

9. Tingkat Konsentrasi dan Berhitung

mudah beralih tidak mampu berkonsentrasi tidak mampu berhitung sederhana
Jelaskan :_______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Masalah keperawatan : _________________________________________________________________

10. Kemampuan Penilaian

gangguan ringan gangguan bermakna
Jelaskan :_______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Masalah keperawatan : _________________________________________________________________

11. Daya Tilik Diri/ Insight

mengingkari penyakit yang diderita menyalahkan hal-hal diluar dirinya
Jelaskan :_______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Masalah keperawatan : _________________________________________________________________

12. Interaksi selama Wawancara

bermusuhan tidak kooperatif mudah tersinggung
kontak mata kurang defensif curiga
Jelaskan :_______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Masalah keperawatan : _________________________________________________________________
VI. FISIK
1. Keadaan umum ________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. Tanda vital: TD:___________N:___________ S:_____________ P:_______
3. UKur: TB:___________ BB:__________ turun naik
4. Keluhan fisik: tidak ya jelaskan...............................
_________________________________________________________________________________
_________________________________________________________________________________
5. Pemeriksaan fisik:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
 ____________________________________________________________________________________
Jelaskan :____________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
Masalah keperawatan : _________________________________________________________________

VII. PENGKAJIAN PSIKOSOSIAL (sebelum dan sesudah sakit)

1. Konsep Diri
a. Citra tubuh :___________________________________________________________________

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

b. Identitas :___________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

c. Peran :___________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

d. Ideal diri :___________________________________________________________________

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

e. Harga diri :___________________________________________________________________

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Masalah keperawatan : _______________________________________________________________

2. Genogram

3. Hubungan Sosial
a. Hubungan terdekat :
___________________________________________________________________________________
___________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
b. Peran serta dalam kelompok/ masyarakat
__________________________________________________________________________________
_____________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
c. Hambatan dalam berhubungan dengan orang lain
__________________________________________________________________________________
_____________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Masalah keperawatan: _______________________________________________________________
__________________________________________________________________________________

4. Spiritual dan kultural

a. Nilai dan keyakinan
__________________________________________________________________________________
__________________________________________________________________________________

b. Konflik nilai/ keyakinan/ budaya

__________________________________________________________________________________
__________________________________________________________________________________
c. Kegiatan ibadah
__________________________________________________________________________________
__________________________________________________________________________________
Masalah keperawatan:____________________________________________________________________
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 _________________________
Tidur malam lama : ______________________ s/d _________________________
Aktivitas sebelum / sedudah tidur : _____________________ s/d ________________________

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
__________________________________________________________________________
__________________________________________________________________________
Masalah berhubungan dengan lingkungan, uraikan
__________________________________________________________________________
__________________________________________________________________________
Masalah dengan pendidikan, uraikan
__________________________________________________________________________
__________________________________________________________________________
Masalah dengan pekerjaan, uraikan
__________________________________________________________________________
__________________________________________________________________________
Masalah dengan perumahan, uraikan
__________________________________________________________________________
__________________________________________________________________________
Masalah dengan ekonomi, uraikan
__________________________________________________________________________
__________________________________________________________________________
Masalah dengan pelayanan kesehatan, uraikan
__________________________________________________________________________
__________________________________________________________________________
Masalah lainnya, uraikan
__________________________________________________________________________
__________________________________________________________________________
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 : _________________________________________________________________
_________________________________________________________________
_________________________________________________________________

XIII. DAFTAR MASALAH KEPERAWATAN

____________________________
____________________________
____________________________
____________________________
____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
XIV. ANALISA DATA

No DATA MASALAH
XV. POHON MASALAH

XVI. DIAGNOSA KEPERAWATAN

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
___________________________________________________________________________________

______________________________
Mahasiswa

______________________________
 PROGRAM STUDI S1 KEPERAWATAN
SEKOLAH TINGGI ILMU KESEHATAN BALI

DAFTAR DIAGNOSA KEPERAWATAN

(Berdasarkan prioritas)
Ruang :
Nama Pasien :
No. Register :

No. TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TANDA

Dx MUNCUL TERATASI TANGAN
 PROGRAM STUDI S1 KEPERAWATAN
SEKOLAH TINGGI ILMU KESEHATAN BALI

IMPLEMENTASI DAN EVALUASI

KEPERAWATAN KESEHATAN JIWA

Nama: _____________________________ Ruangan: ___________________ RM No._____________

No. Tanggal IMPLEMENTASI EVALUASI TANDA

Dx & Jam KEPERAWATAN TANGAN
 PROGRAM STUDI S1 KEPERAWATAN
SEKOLAH TINGGI ILMU KESEHATAN BALI
STRATEGI PELAKSANAAN
TINDAKAN KEPERAWATAN HARI KE..................

A. PROSES KEPERAWATAN
1. Kondisi klien:
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
2. Diagnosa keperawatan:
........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

3. Tujuan khusus:
........................................................................................................................................
........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

4. Tindakan keperawatan:
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN

KEPERAWATAN
ORIENTASI
1. Salam Terapeutik:
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
2. Evaluasi/ Validasi:
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

3. Kontrak: Topik, waktu, dan tempat

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

KERJA: Langkah-Langkah Tindakan keperawatan

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

TERMINASI:
1. Evaluasi respon klien terhadap tindakan keperawatan:
Subyektif:
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

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