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 : ………………………

Jenis Kel. : ………………………

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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III. 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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Diagnosa Keperawatan :
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
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 Anggota keluarga yang gangguan jiwa ?

 Ada
 Tidak
Jika ada :

Hubungan keluarga :

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Gejala :

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Riwayat pengobatan :

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Diagnosa Keperawatan :

IV. PENGKAJIAN PSIKOSOSIAL (Sebelum dan sesudah sakit)

1. Genogram:

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. Harga diri :
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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 :

4. Spiritual
a. Nilai dan keyakinan
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b. Kegiatan ibadah
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Diagnosa Keperawatan:

V. 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 :

VI. 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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Diagnosa Keperawatan :

4. Mood dan Afek

a. Mood
 Depresi  Khawatir
 Ketakutan  Anhedonia
 Euforia  Kesepian
 Lain lain
Jelaskan
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b. Afek
 Sesuai  Tidak sesuai
 Tumpul/dangkal/datar  Labil
Jelaskan:

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Diagnosa Keperawatan

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  Asosiai 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
 Pikiran bunuh diri o Kebesaran
 Preokupasi o Kejar / curiga
 Pikiran isolasisosial o Nihilistik
 Ide yang terkait o Dosa
 PikiranRendahdiri 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 dayaingat jangka menengah ( 24 jam - ≤ 1 bulan)
 Gangguan daya ingat pendek (kurun waktu 10 detik sampai 15 menit)
Jelaskan:
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Diagnosa Keperawatan:
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 10. Tingkat Konsentrasi dan Berhitung
a. Konsentrasi
 Mudah beralih
 Tidak mampu berkonsentrasi
Jelaskan:
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b. Berhitung
Jelaskan:
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Diagnosa Keperawatan:
11. Kemampuan Penilaian
 Gangguan ringan
 Gangguan bermakna
Jelaskan :
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Diagnosa Keperawatan:
12. Daya Tilik Diri
 Mengingkari penyakit yang diderita
 Menyalah kanhal-hal diluar dirinya
Jelaskan:
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Diagnosa Keperawatan:

VII.KEBUTUHAN PERSIAPAN PULANG

1. Kemampuan klien memenuhi kebutuhan
 perawatan kesehatan,
 transportasi,
 tempat tinggal.
 Keuangan dan kebutuhan lainnya.

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 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

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:
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 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

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Diagnosa Keperawatan:

VIII. MEKANISME KOPING

Jelaskan :
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Diagnosa Keperawatan:

IX. 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

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 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:

X. 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

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  Penyakit/gangguan jiwa  Penatalaksanaan
 Sistem pendukung  Lain-lain, jelaskan
 Faktor presipitasi
Jelaskan :
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Diagnosa Keperawatan:

XI. ASPEK MEDIS

1. Diagnosis Multi Axis
Axis I : ..........................................................................................................................
Axis II : .........................................................................................................................
Axis III :..........................................................................................................................
Axis IV :..........................................................................................................................
Axis V : .........................................................................................................................
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2. Terapi Medis
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XII.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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XIII. DAFTAR DIAGNOSA KEPERAWATAN

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

XIV. POHON MASALAH

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XV. PRIORITAS DIAGNOSA KEPERAWATAN
1. ……………………………………………….
2. ………………………………………………
3. ………………………………………………
4. .………………………………………………

Lawang, ……………………….

Perawat yang mengkaji

____________________

NIM/NIRM: ..………….

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 TINDAKAN KEPERAWATAN JIWA

Nama : Tn. R Ruang : Parkit

No CM : 133136 Unit :

Tgl No.Dx Dx. Keperawatan Perencanaan

Tujuan Kriteria hasil Intervensi
TUM : Pasien mampu membina hubungan Bina hubungan saling percaya dengan
Pasien dapat mengontrol saling percaya dengan perawat dengan menggunakan prinsip komunikasi terapeutik
halusinasi yang dialaminya kriteria: 1. Sapa pasien dengan ramah baik verbal
Gangguan
1. Ekspresi bersahabat maupun non verbal
persepsi sensori:
TUK 1 : 2. Menunjukkan rasa senang 2. Perkenalkan nama, nama panggilan dan
halusinasi
Pasien dapat membina 3. Ada kontak mata tujuan perawat berkenalan
hubungan saling percaya 4. Mau berjabat tangan 3. Tanyakan nama lengkap dan panggilan yang
5. Mau menyebutkan nama disukai pasien
6. Mau membalas salam 4. Buat kontrak yang jelas
7. Mau duduk berdampingan dengan 5. Tunjukkan sikap jujur dan menunjukkan
perawat sikap empati serta menerima apa adanya
8. Mau mengungkapkan perasaannya 6. Beri perhatian kepada pasien dan perhatikan
kebutuhan dasar pasien
7. Beri kesempatan pasien untuk
mengungkapkan perasaannya
8. Dengarkan ungkapan pasien dengan penuh
perhatian pada ekspresi perasaan pasien

TUK 2 : Pasien dapat menyebutkan: 1. Adakan kontak sering dan singkat secara
Pasien dapat mengenal a. Isi bertahap
halusinasinya b. Waktu 2. Observasi tingkah laku yang terkait dengan
c. Frekuensi halusinasi (verbal dan non verbal)
d. Situasi dan kondisi yang 3. Bantu mengenal halusinasinya
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 menimbulkan halusinasi a. Jika menemukan pasien sedang
halusinasi, tanyakan apakah ada
suara/bisikan yang didengar atau melihat
bayangan tanpa wujud atau merasakan
sesuatu yang tidak ada
b. Jika pasien menjawab iya, lanjutkan apa
yang dialaminya
c. Katakan bahwa perawat percaya pasien
mengalami hal tersebut, namun perawat
sendiri tidak mengalaminya (dengan nada
bersahabat, tidak menuduh dan
menghakimi)
d. Katakan bahwa ada pasien lain yang
mengalami seperti pasien
e. Katakan bahwa perawat akan membantu
pasien
4. Jika pasien tidak sedang berhalusinasi,
klarifikasi tentang adanya pengalaman
halusinasi, diskusikan dengan pasien: isi,
waktu daan frekuensi halusinasi (pagi,
siang, sore, malam atau sering, jarang),
situasi dan kondisi yang dapat memicu
muncul atau tidaknya halusinasi
5. Diskusi tentang apa yang dirasakan saat
terjadi halusinasi
6. Dorong untuk mengungkapkan perasaan
saat terjadi halusinasi
7. Diskusikan tentang dampak yang akan
dialaminya jika pasien menikmati
halusinasinya

TUK 3 : Pasien menyebutkan tindakan yang a. Identifikasi bersama tentang cara tindakan

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Pasien dapat mengontrol biasanya dilakukan untuk jika terjadi halusinasi
halusinasinya mengendalikan halusinasinya b. Diskusikan manfaat cara yang digunakan
pasien
Pasien mampu menyebutkan cara baru 1. Jika cara tersebut adaptif beri pujian
mengontrol halusinasinya 2. Jika ma adaptif diskusikan dengan
pasien kerugian cara tersebut
Pasien dapat memilih dan a. Diskusikan cara baru untuk
mendemonstrasikan cara mengatasi memutus/mengontrol halusinasi paisen
halusinasi 1. Menghardik halusinasi: katakan pada
diri sendiri bahwa ini tidak nyata (saya
Pasien melaksanakan cara yang dipilih tidak mau mendengar/ ... pada saat
untuk mengendalikan halusinasinya halusinasi terjadi)
2. Menemui orang lain untuk bercakap-
Pasien mengikuti terapi aktivitas cakap jika halusinasi datang
kelompok 3. Membuat dan melaksanakan jadual
kegiatan sehari-hari yang telah disusun
4. Memberikan pendidikan kesehatan
tentang penggunaan obat untuk
mengendalikan halusinasinya
a. Bantu paisen memilih cara yang sudah
dianjurkan dan latih untuk mencobanya
b. Pantau pelaksanaan tindakan yang telah
dipilih dan dilatih, jika berhasil beri pujian
c. Libatkan pasien dalam TAK : stimulasi
persepsi

TUK 4 : Keluarga menyatakan setuju untuk a. Buat kontrak pertemuan dengan keluarga
Pasien dapat dukungan mengikuti pertemuan dengan perawat (waktu, tempat, topik)
dari keluarga dalam b. Diskusikan dengan keluarga:
mengontrol halusinasinya Keluarga menyebutkan pengertian, 1. Pengertian halusinasi
tanda dan gejala, proses terjadinya dan 2. Tanda dan gejala
tindakan untuk mengendalikan 3. Proses terjadinya

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 halusinasinya 4. Cara yang bisa dilakukan oleh pasien
dan keluarga untuk memutus halusinasi
5. Obat-obat halusinasi
6. Cara merawat pasien halusinasi dirumah
7. Beri informasi waktu follow up atau
kapan perlu mendapat bantuan
a. Beri reinforcement positif atas keterlibatan
keluarga

TUK 5 : Pasien menyebutkan: 1. Diskusikan tentang manfaat dan kerugian

Pasien dapat menggunakan 1. Manfaat minum obat tidak minum obat, dosis, nama, frekuensi,
obat dengan benar 2. Kerugian tidak minum obat efek dan efek samping minum obat
3. Nama, warna, dosis, efek terapi, 2. Pantau saat pasien minum obat
efek samping 3. Anjurkan pasien minta sendiri obatnya pada
perawat
Pasien mendemonstrasikan 4. Beri reinforcement jika pasien
penggunaan obat dengan benar menggunakan obat dengan benar
5. Diskusikan akibat berhenti minum obat
Pasien menyebutkan akibat berhenti tanpa konsultasi dengan dokter
minum obat tanpa konsultasi dengan 6. Anjurkan pasien berkonsultasi dengan
dokter dokter/perawat jika terjadi hal-hal yang
tidak diinginkan.

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Keterangan :

Cara pendokumentasian :

 Mengacu pada fase-fase komunikasi terapeutik

 Pada kolom waktu diisi : Dx. Kep, Tanggal & jam tindakan
 Pada kolom Tindakan Keperawatan diisi :
 Fase Oreantasi : Saat evaluasi/ validasi
 Fase kerja : Sesuai tindakan fase kerja
 Fase terminasi: Rencana Tindak Lanjut
 Kolom Evaluasi:
 Evaluasi subyektif & Obyektif
 Berdasarkan respon subyektif, evaluasi obyektif
 Sesuai hasil evaluasi respon subyektif & obyektif pada fase terminasi
 A : Analisa , Sesuai dengan hasil interaksi terakhir
 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