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. DataPrimer
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b. DataSekunder
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c. Keluhan Utama Saat Pengkajian
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III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)

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1. Faktor Penyebab/Pendukung :
a. Riwayat Trauma
Usia Pelaku Korban Saksi
1. Aniayafisik ………… ………… ………… …………
2. Aniayaseksual ………… ………… ………… …………
3. Penolakan ………… ………… ………… …………
4. Kekerasan dalam keluarga ………… ………… ………… …………
5. Tindakan kriminal ………… ………… ………… …………
Jelaskan:
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b. Pengalaman masalalu yang tidak menyenangkan (peristiwa kegagalan, kematian,
perpisahan )
Jika ada jelaskan :
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DiagnosaKeperawatan :
c. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
Jika yaJelaskan
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Diagnosa Keperawatan :
2. Upaya yang telah dilakukan terkait kondisi di atas dan hasilnya :
Jelaskan :
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Diagnosa Keperawatan :
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. Hargadiri :
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Diagnosa Keperawatan :
2. 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. Hambatandalamberhubungandengan orang lain
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Diagnosa Keperawatan :
3. Spiritual
a. Nilai dan keyakinan
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Diagnosa Keperawatan:
IV. 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:
Jelaskan :
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Diagnosa Keperawatan :
V. 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. Aktifitasmotorik/Psikomotor
Kelambatan :
Jelaskan:
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Diagnosa Keperawatan :
4. Mood dan Afek
a. Mood Jelaskan
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b. Afek
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 Diagnosa Keperawatan
5. Interaksi Selama Wawancara
Jelaskan:
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Diagnosa Keperawatan
6. Persepsi Sensorik
Jelaskan:
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Diagnosa Keperawatan
7. Proses Pikir
a. ArusPikir:
Jelaskan:
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b. Isi Pikir
Jelaskan:
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c. Bentuk pikir :
Jelaskan:
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Diagnosa Keperawatan:
8. Kesadaran
Jelaskan:
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Diagnosa Keperawatan:
9. Memori
Jelaskan:
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Diagnosa Keperawatan:

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10. Tingkat Konsentrasi dan Berhitung
a. Konsentrasi
Jelaskan:
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b. Berhitung
Jelaskan:
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Diagnosa Keperawatan:
11. Kemampuan Penilaian
Jelaskan :
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Diagnosa Keperawatan:
12. Daya Tilik Diri
Jelaskan:
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Diagnosa Keperawatan:
a. 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:
b. 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
Jelaskan
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Diagnosa Keperawatan:
1. 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:
2. Sistem Pendukung Ya Tidak
Keluarga 
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
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Diagnosa Keperawatan:
VI. MEKANISME KOPING
Jelaskan :
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Diagnosa Keperawatan:
VII.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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VIII. 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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IX. DAFTAR DIAGNOSA KEPERAWATAN
1. ………………………………………
2. ………………………………………
3. ………………………………………
4. ………………………………………
5. ………………………………………
6. ………………………………………
7. ………………………………………
8. dst

X. POHON MASALAH

XI. PRIORITAS DIAGNOSA KEPERAWATAN

1. ……………………………………………….
2. ………………………………………………
3. ………………………………………………
4. .………………………………………………
RSI HASANAH,
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Perawat yang mengkaji

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NIM/NIRM: ..………….

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 TINDAKAN KEPERAWATAN JIWA
Nama : Ruang :
No CM : Unit :
Tanggal Diagnosa
No Tindakan Keperawatan Evaluasi Ttd
Jam Keperawatan

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Keterangan :
Cara pendoku mentasian :
 Mengacu pada fasefase komunikasi terapeutik
 Pada kolom waktu diisi : Dx. Kep, Tanggal & jam tindakan
 Pada kolom Tindakan Keperawatan diisi :
 Fase Oreantasi : Saat evaluasi/ validasi
 Fasekerja : Sesuai tindakan fase kerja
 Fase terminasi : Rencana Tindak Lanjut
 KolomEvaluasi:
 Evaluasi subyektif & Obyektif
 Berdasarkan respon subyektif, evaluasi obyektif
 Sesuai hasil evaluasi respon subyektif & obyektif pada fase terminasi
 A : Analisa , Sesuai dengan hasilin teraksi terakhir
 P : Planning , terdiridari 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