PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

Tanggal MRS : ………………..

TanggalDirawat di Ruangan : ………………..
TanggalPengkajian : ……………........
RuangRawat : …………………

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. KeluhanUtamaSaatPengkajian
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III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)
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III. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)

1. Pernahmengalamigangguanjiwa di masalalu?
 Ya
 Tidak
JikaYa,Jelaskan kapan, tanda gejala/keluhan :
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2. Faktor Penyebab/Pendukung :
a. Riwayat Trauma
Usia Pelaku Korban Saksi
1. Aniayafisik ………… ………… ………… …………
2. Aniayaseksual ………… ………… ………… …………
3. Penolakan ………… ………… ………… …………
4. Kekerasandalamkeluarga ………… ………… ………… …………
5. Tindakan kriminal ………… ………… ………… …………
Jelaskan:
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DiagnosaKeperawatan :
b. Pernahmelakukanupaya / percobaan / bunuhdiri
Jelaskan:
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DiagnosaKeperawatan :

c. Pengalamanmasalalu yang tidakmenyenangkan (peristiwakegagalan, kematian,

perpisahan )
Jikaadajelaskan :
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DiagnosaKeperawatan :
d. Pernahmengalamipenyakitfisik (termasukgangguantumbuhkembang)
 Ya
 Tidak
JikayaJelaskan
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DiagnosaKeperawatan :
 e. RiwayatPenggunaanNAPZA
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DiagnosaKeperawatan :
3. Upaya yang telah dilakukanterkaitkondisi di atas dan hasilnya :
Jelaskan:
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DiagnosaKeperawatan :
4. RiwayatPenyakitKeluarga
Anggotakeluarga yang gangguanjiwa ?
 Ada
 Tidak
Jikaada:
Hubungankeluarga:
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Gejala:
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Riwayatpengobatan:
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DiagnosaKeperawatan:
IV. PENGKAJIAN PSIKOSOSIAL (Sebelumdansesudahsakit)
1. Genogram:

Jelaskan:
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DiagnosaKeperawatan :
2. KonsepDiri
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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DiagnosaKeperawatan :
3. HubunganSosial
a. Orang yang berarti/terdekat
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b. Peransertadalamkegiatankelompok/masyarakat dan hubungan sosial
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c. Hambatandalamberhubungandengan orang lain
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DiagnosaKeperawatan :
4. Spiritual
a. Nilaidankeyakinan
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b. Kegiatanibadah
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DiagnosaKeperawatan:
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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DiagnosaKeperawatan :
VI. STATUS MENTAL
1. Penampilan (Penanpilan usia, cara perpakaian, kebersihan)
Jelaskan:
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DiagnosaKeperawatan:
2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter) :
Jelaskan:
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DiagnosaKeperawatan:
3. Aktifitas motorik/Psikomotor
Kelambatan :
 Hipokinesia,hipoaktifitas
 Katalepsi
 Sub stupor katatonik
 Fleksibilitasserea
 Jelaskan:
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Peningkatan :
 Hiperkinesia,hiperaktifitas  Grimace
 Stereotipi  Otomatisma
 GaduhGelisahKatatonik  Negativisme
 Mannarism  Reaksikonversi
 Katapleksi  Tremor
 Tik  Verbigerasi
 Ekhopraxia  Berjalankaku/rigid
 Command automatism  Kompulsif :sebutkan …………

Jelaskan:
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DiagnosaKeperawatan:
4. Mood dan Afek
a. Mood
 Depresi  Khawatir
 Ketakutan  Anhedonia
 Euforia  Kesepian
 Lain lain
Jelaskan
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 b. Afek
 Sesuai  Tidaksesuai
 Tumpul/dangkal/datar  Labil
Jelaskan:
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DiagnosaKeperawatan
5. Interaksi Selama Wawancara
Bermusuhan  Kontakmatakurang
Tidak kooperatif  Defensif
 Mudahtersinggung  Curiga
Jelaskan:
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DiagnosaKeperawatan
6. Persepsi Sensorik
a. Halusinasi
 Pendengaran
 Penglihatan
 Perabaan
 Pengecapan
 Penciuman
b. Ilusi
 Ada
 Tidakada
Jelaskan:
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DiagnosaKeperawatan
7. Proses Pikir
a. ArusPikir:
 Koheren  Inkoheren
 Sirkumtansial  Asosiasilonggar
 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
 Pikiranbunuhdiri o Kebesaran
 Preokupasi o Kejar / curiga
 Pikiranisolasisosial o Nihilistik
 Ide yang terkait o Dosa
 PikiranRendahdiri o Sisippikir
 Pesimisme o Siar piker
 Pikiranmagis o Kontrolpikir
 Pikirancuriga  Lain lain :
Jelaskan:
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c. Bentuk pikir :
  Realistik
 Non realistik
 Dereistik
 Otistik
Jelaskan:
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DiagnosaKeperawatan:
8. Kesadaran
 Orientasi (waktu, tempat, orang)
Jelaskan:
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 Meninggi
 Menurun:
 Kesadaranberubah
 Hipnosa
 Confusion
 Sedasi
 Stupor
Jelaskan:
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DiagnosaKeperawatan:
9. Memori
 Gangguandayaingatjangkapanjang ( > 1 bulan)
 Gangguandayaingatjangkamenengah ( 24 jam - ≤ 1 bulan)
 Gangguandayaingatpendek (kurunwaktu 10 detiksampai 15 menit)
Jelaskan:
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DiagnosaKeperawatan:
10. Tingkat KonsentrasidanBerhitung
a. Konsentrasi
 Mudahberalih
 Tidakmampuberkonsentrasi
Jelaskan:
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b. Berhitung
Jelaskan:
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DiagnosaKeperawatan:
11. KemampuanPenilaian
 Gangguan ringan
 Gangguan bermakna
Jelaskan :
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 DiagnosaKeperawatan:
12. DayaTilikDiri
 Mengingkaripenyakit yang diderita
 Menyalahkanhal-haldiluardirinya
Jelaskan:
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DiagnosaKeperawatan:
VII.KEBUTUHAN PERSIAPAN PULANG
1. Kemampuanklienmemenuhikebutuhan
 Perawatankesehatan,
 transportasi,
 tempattinggal.
 Keuangandankebutuhanlainnya.
Jelaskan:
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2. KegiatanHidupSeharihari
a. Perawatandiri
1) Mandi
Jelaskan :
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2) Berpakaian, berhiasdanberdandan
Jelaskan :
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3) Makan
Jelaskan :
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4) Toileting (BAK, BAB)
Jelaskan :
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DiagnosaKeperawatan:
b. Nutrisi
Berapafrekwensimakandanfrekwensikudapandalamsehari.
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Bagaimananafsumakannya
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Bagaimanaberatbadannya.
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DiagnosaKeperawatan:
c. Tidur
1) Istirahatdantidur
Tidursiang, lama : ____________ s/d _____________
Tidurmalam, lama : _____________ s/d _____________
Aktifitassebelum/sesudahtidur : __________ , _________
Jelaskan
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2) Gangguantidur
 Insomnia
 Hipersomnia
 Parasomnia
 Lain lain
Jelaskan
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DiagnosaKeperawatan:
3. Kemampuan lain lain
 Mengantisipasikebutuhanhidup
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 Membuatkeputusanberdasarkankeinginannya,
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 Mengaturpenggunaanobatdanmelakukanpemeriksaankesehatannyasendiri.
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DiagnosaKeperawatan:
4. Sistem Pendukung Ya Tidak
Keluarga
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
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DiagnosaKeperawatan:
VIII. MEKANISME KOPING
Jelaskan :
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DiagnosaKeperawatan:
IX. MASALAH PSIKOSOSIALDAN LINGKUNGAN
 Masalah dengan dukunga nkelompok, spesifiknya
Jelaskan :
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 Masalahberhubungandenganlingkungan, spesifiknya
Jelaskan :
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 Masalahdenganpendidikan, spesifiknya
Jelaskan :
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 Masalahdenganpekerjaan, spesifiknya
 Jelaskan :
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 Masalahdenganperumahan, spesifiknya
Jelaskan :
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 Masalahdenganekonomi, spesifiknya
Jelaskan :
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 Masalahdenganpelayanankesehatan, spesifiknya
Jelaskan :
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 Masalahlainnya, spesifiknya
Jelaskan :
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DiagnosaKeperawatan:
X. ASPEK PENGETAHUAN
Apakahklienmempunyaimasalah yang berkaitandenganpengetahuan yang
kurangtentangsuatuhal?
Bagaimanapengetahuanklien/keluargasaatinitentangpenyakit/gangguanjiwa,
perawatandanpenatalaksanaanyafaktor yang memperberatmasalah (presipitasi), obat-
obatanataulainnya.Apakahperludiberikantambahanpengetahuan yang
berkaitandenganspesifiknyamasalahtsb.
 Penyakit/gangguanjiwa  Penatalaksanaan
 Sistempendukung  Lain-lain, jelaskan
 Faktorpresipitasi
Jelaskan :
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DiagnosaKeperawatan:
XI. ASPEK MEDIS
1. Diagnosis Medis :
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2. Diagnosa Multi Axis
Axis I : ..........................................................................................................................
Axis II :..........................................................................................................................
Axis III :..........................................................................................................................
Axis IV :..........................................................................................................................
Axis V :..........................................................................................................................
3. 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

XV. PRIORITAS DIAGNOSA KEPERAWATAN

1. ……………………………………………….
2. ………………………………………………
3. ………………………………………………
4. .………………………………………………

Lawang, ……………………….
Mahasiswa yang mengkaji
____________________
NIM................................
 TINDAKAN KEPERAWATAN JIWA
Nama : Ruang :
No CM : Unit :
No TindakanKeperawatan Evaluasi
Keterangan :
Cara pendokumentasian :
 PadakolomTindakanKeperawatandiisi :
 Tanggal& jam tindakan
 Data (Tanda gejala dan kemampuan)
 Diagnosa Keperawatan
 Tindakan Keperawatan
 KolomEvaluasi:
 Evaluasisubyektif&Obyektif
 Berdasarkanresponsubyektif, evaluasiobyektif
 Sesuaihasilevaluasiresponsubyektif&obyektifpadafaseterminasi
 A : AnalisaSesuaikemampuan Pasien
 P : Planning , terdiridari P pasiendan P perawat
 P pasien : berdasarkanhasilrencanatindaklanjutpadafaseterminasi
 P perawat : berdasarkanhasilkontrak yang
akandatangpadafaseterminasi