ASUHAN KEPERAWATAN JIWA PADA .......

DENGAN MASALAH KEPERAWATAN ...........................................

DI PUSKESMAS ..................................
TANGGAL 11 – 28 MARET 2020\

I. PENGKAJIAN
A. Identitas Klien
Nama : ................................................................
Umur : ................................................................
Jenis Kelamin : laki-laki ................................................................
Suku : Sasak................................................................
Agama : ................................................................
Status Perkawinan : ................................................................
Alamat : ................................................................
Diagnosa Medis : ................................................................
Tanggal Dirawat : ................................................................
Tanggal Pengkajian : ................................................................

B. Keluhan Utama/Saat Dikaji

1. Keluhan Utama :
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Keluhan Saat Di Kaji :
Klien mengatakan terkadang mendengar suara bisikan yang tidak jelas klien
mengatakan biasanya mendengar bisikan saat klien melamun klien
mendengar bisikan mengejek dirinya tidak tahu malu dan hidup selalu
menyusahkan klien merespon suara tersebut dengan perasaan gelisah klien
mengatakan terkadang malu untuk berinteraksi dengan temannya atau
orang lain karena takut tidak nyambung saat berbicara klien mengatakan
malu tidak memiliki kemampuan apapun dan malu terhadap dirinya sendiri
klien mengatakan malu jika keluar nanti dikatakan sakit dan pernah dirawat
rumah sakit jiwa lain mengatakan jarang mandi dan mandi jika klien
berkeringat saja
MK : halusinasi pendengaran harga diri rendah defisit perawatan diri

C. Faktor Predisposisi
1. Pernah mengalami gangguan jiwa
Klien mengatakan pernah mengalami gangguan jiwa dan masuk rumah sakit
jiwa
2. Pengobatan sebelumnya
Klien mengatakan baru keluar dari rumah sakit jiwa seminggu yang lalu.......
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 3. Aniaya fisik
Klien mengatakan tidak pernah nah mengalami aniaya fisik...........................
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4. Anggota keluarga yang mengalami gangguan jiwa
Klien mengatakan Kakaknya juga mengalami gangguan jiwa.........................
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5. Pengalaman masa lalu yang tidak menyenangkan
Klien mengatakan tidak pernah mengalami masa lalu yang tidak
menyenangkan.................................................................................................
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MK :.........................................................................................................................
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D. Pemeriksaan Fisik
1. Tanda-Tanda Vital
Tekanan Darah : ............... mmHg
Nadi : ............... X/Menit
Respirasi : ............... X/Menit
Suhu : ............... 0C
2. Antropometri
BB : ........... Kg
TB : ........... Cm
3. Keluhan Fisik
Klien mengatakan pusing.................................................................................
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MK :.........................................................................................................................
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E. Psikososial
1. Genogram
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Keterangan :

2. Konsep Diri
a. Citra Tubuh
Klien mengatakan merasa bersyukur memiliki tubuh yang lengkap.........
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b. Identitas Diri
Klien mengatakan identitasnya saat ini adalah sebagai seorang laki-laki
klien mampu menyebutkan nama alamat agama dan pendidikannya......
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c. Peran Diri
Klien mengatakan dirinya di rumah berperan sebagai ayah rumah
tangga........................................................................................................
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d. Harga Diri
Klien mengatakan anne-marie rasa malu untuk berinteraksi dengan
temannya atau orang lain karena takut tidak nyambung pembicaraannya
Kelayan mengatakan malu karena tidak memiliki pekerjaan klien
mengatakan malu jika keluar nanti dikatakan sakit dan pernah dirawat di
rumah sakit jiwa.........................................................................................
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e. Ideal Diri
Klien mengatakan Jika iya harus memiliki pekerjaan dan akan berusaha
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MK : harga diri rendah......................................................................................
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 3. Hubungan Sosial
a. Orang yang berarti
Klien mengatakan orang yang paling berarti dalam hidupnya adalah istri
dan anak-anaknya......................................................................................
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b. Hambatan dalam berhubungan dengan orang lain
Klien mengatakan Saat berinteraksi dengan orang lain kadang tidak
nyambung hal itu yang menyebabkan dirinya merasa malu hal itu yang
menyebabkan dirinya merasa malu...........................................................
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c. Peran serta dalam kelompok atau masyarakat
Klien mengatakan dahulu sering menjalani aktivitas di masyarakat.........
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MK : harga diri rendah .....................................................................................

4. Spiritual
a. Nilai dan Keyakinan
Klien mengatakan dirinya adalah seorang Hindu dan Percaya adanya
Tuhan.........................................................................................................
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b. Kegiatan Ibadah
Klien mengatakan rajin beribadah.............................................................
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MK : .................................................................................................................

F. Status Mental
1. Penampilan
Klien terlihat sedikit rapi tampak kuning dan kurang bersih kuku dan jari
sedikit kotor.......................................................................................................
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MK : defisit perawatan diri................................................................................
2. Pembicaraan
Klien berbicara dengan tidak teratur dan terkadang tidak sesuai dengan
pertanyaan yang dilontarkan atau yang diberikan...........................................
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MK : .................................................................................................................
3. Aktifitas Motorik
 Klien mampu menggerakkan semua anggota tubuhnya..................................
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MK : .................................................................................................................

4. Alam Perasaan
Klien mengatakan sedih dengan tidak adanya istri dan anak-anaknya di
rumah yang sama karena istri dan anak-anaknya sedang berada ada di
rumah mertua...................................................................................................
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MK : .................................................................................................................
5. Afek
Klien memiliki emosi yang stabil.......................................................................
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MK : .................................................................................................................
6. Interaksi Selama Wawancara
Klien sedikit kooperatif selama wawancara dan mampu menjawab
pertanyaan walaupun jawabannya sedikit melenceng dari pertanyaan..........
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MK : .................................................................................................................
7. Persepsi
Klien mengatakan terkadang mendengar suara bisikan yang mengatakan
dirinya tidak tahu malu dan hidup selalu menyusahkan klien mendengar saat
dirinya melamun...............................................................................................
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MK : halusinasi pendengaran...........................................................................
8. Proses Pikir
Klien menjawab pertanyaan perawat dengan singkat dan sedikit ngelantur...
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MK : .................................................................................................................
9. Isi Pikir
Klien mengatakan takut jika bisikan itu datang lagi.........................................
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MK : halusinasi pendengaran..........................................................................
10. Tingkat Kesadaran
Tingkat kesadaran klien composmentis mampu berorientasi dengan ruang
waktu dan tempat.............................................................................................
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 MK : .................................................................................................................
11. Memori
Klien tidak mengalami gangguan memori jangka panjang yaitu klien masih
mengingat pendidikan terakhirnya Kalian juga tidak mengalami gangguan
memori jangka pendek yaitu klien mampu menjelaskan aktivitas yang
dilakukannya.....................................................................................................
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MK : .................................................................................................................
12. Tingkat Konsentrasi dan Berhitung
Klien mampu berkonsentrasi dan berhitung penjumlahan atau pengurangan
sederhana.........................................................................................................
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MK : .................................................................................................................
13. Kemampuan Penilaian
Klien mampu mengambil keputusan sederhana seperti mencuci tangan
sebelum dan sesudah makan..........................................................................
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MK :..................................................................................................................
14. Daya Tilik Diri
Klient mengatakan tahu dan tidak menyangkal jika dirinya sakit.....................
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MK : .................................................................................................................

G. Kebutuhan Di rumah
1. Makan
Klien mengatakan makan 3 kali sehari............................................................
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2. Defekasi/Berkemih
Klien mengatakan BAB 1 kali sehari pada pagi hari dan BAK 4 sampai 5 kali
sehari................................................................................................................
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3. Mandi
Klien mengatakan jarang mandi mandi seperlunya jika berkeringat dan
jarang membersihkan gigi................................................................................
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4. Berpakaian
Klien mengatakan ganti baju jika kotor............................................................
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 5. Istirahat dan Tidur
Klien mengatakan jika pusing langsung tidur...................................................
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6. Penggunaan Obat
Klien mengatakan akan rajin minum obat........................................................
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7. Pemeliharaan Kesehatan
Klien mengatakan akan sering mengontrol keadaannya di pelayanan
kesehatan.........................................................................................................
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8. Aktifitas di Dalam Rumah

Klien mengatakan hanya tidur karena sering merasa pusing.......................
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9. Aktifitas di Luar Rumah
Klien mengatakan tidak pernah keluar dari lingkungan rumah........................
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MK : ........................................................................................................................
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H. Mekanisme Koping
Klien mengatakan jika rindu dengan istri dan anak-anaknya hanya bisa
menelpon................................................................................................................
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MK : ........................................................................................................................
I. Masalah Psikososial dan Lingkungan
1. Masalah dengan Dukungan Kelompok
Klien mengatakan selalu mendapat dukungan dari semua anggota
keluarganya......................................................................................................
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MK : .................................................................................................................
2. Masalah dengan Lingkungan
Klien mengatakan sulit untuk memulai percakapan dengan orang lain...........
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 MK : .................................................................................................................
3. Masalah dengan Pendidikan
Klien mengatakan sekolah sampai D1 pariwisata...........................................
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MK : .................................................................................................................
4. Masalah dengan Pekerjaan
Klien mengatakan tidak memiliki pekerjaan.....................................................
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MK : .................................................................................................................
5. Masalah dengan Perumahaan
Klien mengatakan tinggal serumah dengan orang tua....................................
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MK : .................................................................................................................
6. Masalah dengan Ekonomi
Klien mengatakan tidak memiliki uang.............................................................
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MK : .................................................................................................................
7. Masalah dengan Pelayanan Kesehatan
Klien mengatakan tidak memiliki masalah dengan pelayanan kesehatan......
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MK : .................................................................................................................

J. Pengetahuan
Klien mengatakan tidak mengetahui tentang penyakitnya.....................................
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MK : ........................................................................................................................

K. Aspek Medik
1. Diagnosa Medik : skizofrenia...........................................................................
2. Terapi Medik
a. .....................................................
b. .....................................................
c. .....................................................
d. .....................................................
e. .....................................................

L. Daftar Masalah Keperawatan

1. Halusinasi pendengaran...........................................................
2. Harga diri rendah...........................................................
 3. Defisit perawatan diri...........................................................
4. Koping individu inefektif...........................................................
5. Kurang pengetahuan...........................................................
6. ...........................................................
7. ...........................................................
8. ...........................................................
9. ...........................................................
10. ...........................................................

M. Pohon Masalah
II. DIAGNOSA KEPERAWATAN
A. Analisa Data
N DATA FOKUS MASALAH KEPERAWATAN
O Ds. Halusinasi pendengaran
1. - klien mengatakan terkadang
mendengar suara bisikan yang tidak
jelas
- klien terkadang mendengar suara
mengejek dirinya tidak tahu malu dan
hidup selalu menyusahkan
- klien mengatakan mendengar saat
melamun dan merespon suara dengan
gelisah

Do
- klien tampak gelisah
- klien jarang berinteraksi dengan
temannya dan orang sekitar
- kontak mata kurang

2 Ds. Harga diri rendah

- klien mengatakan malu berinteraksi
dengan temannya atau orang lain karena
takut tidak nyambung saat bicara
- klien mengatakan malu jika keluar nanti
dikatakan sakit dan pernah dirawat di
RSJ

Do.
- klien tampak jarang berinteraksi dan
selalu merasa tidak memiliki kemampuan
apapun

3 Ds. Defisit perawatan diri

-Klien mengatakan jarang mandi mandi
jika berkeringat saja

Do
- klien tampak kurang rapi
- tidak wangi
- Gigi tampak kotor
N DATA FOKUS MASALAH KEPERAWATAN
O
B. Daftar Diagnosa Keperawatan
1. Halusinasi pendengaran
2. Harga diri rendah
3. Defisit perawatan diri
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III. INTERVENSI KEPERAWATAN
Nama Klien : Puskesmas :
Alamat :

DX. RENCANA TINDAKAN KEPERAWATAN

KEP TUJUAN KRITERIA EVALUASI INTERVENSI
DX. RENCANA TINDAKAN KEPERAWATAN
KEP TUJUAN KRITERIA EVALUASI INTERVENSI
IV. IMPLEMENTASI DAN EVALUASI

TANGGA DX.
IMPLEMENTASI EVALUASI PARAF
L KEP
TANGGA DX.
IMPLEMENTASI EVALUASI PARAF
L KEP
 STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Masalah :
Pertemuan :
Tanggal :
Waktu :